Keio Academy of New York—Payment Information

If you have questions, please feel free to contact us. VISA or MASTERCARD ONLY.

Donor's Information

Description Annual Giving
Student Name First Name: Last Name:
 ex: Taro  Keio   (If you are parents of Keio's student, please specify.)
Graduate Year
 ex: 2012   (If you are a Keio NY Alumni member.)
Current Employer  ex: Keio Academy of New York
Anonymous   Anonymous Donation
Amount * $500 x Units       ($500/Unit)

 * required item

Billing Information

Name * First Name: Last Name:
ex: Taro  Keio
E-Mail *  ex:
Street Address *  ex: 2-15-45 Mita
City *  ex: Minato-ku
State *  ex: Tokyo
Postcode *  ex: 108-8345
Country *  ex: JAPAN
Phone Number *  ex: 03-1111-1111
Fax Number  ex: 03-1111-1112

 * required item
• 情報は全て半角英文字で入力してください。