FORM

Sasamasamune Brewery Reconstruction Support — Donation Form

I hereby apply to donate to support Sasamasamune Brewery, which was damaged by a fire, as described below.

* Submitting this form is optional. A bank transfer alone is also acceptable.

* Please make sure your remitter name is identifiable when sending the transfer.

* For credit card donations, please fill in the required fields and proceed to the payment step.

Application Date

Full Name (or Organization)Required

Address

Phone NumberRequired

Email AddressRequired

Amount (JPY)Required

Please donate JPY 1,000 or more, in increments of 1,000.

Notes

Payment MethodCredit CardYou will be redirected to a secure hosted checkout page. Visa / Mastercard / JCB / American Express / Diners accepted. Payments are processed securely by Square — your card details are encrypted and never stored on this site. Your card statement will show the descriptor "フクシマケンシュゾウキョウドウクミアイ" (Fukushima Sake Brewers Cooperative Association). About the credit card descriptor

The personal information you provide will only be used for the operation of this fund and for payment confirmation. I agree to the above.

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