Gunma University Fund Donations Form
Date: [][], [20To: President, Gunma University
I hereby affirm my support of the aims of the Gunma University Fund and donate as follows:□ Individual
Name
Address
TelephonenumberE-mail(Insert a tick in the relevant box)

□ Alumnus□ Current Student(Department

Faculty, Department / School[Month]Relationshipwith Gunma
University[Year]□ Family of Alumnus

Graduated / Admitted)□ Family of Current Student(Alumnus / Current Student Name
Department

Faculty, Department / School[Month]□ Faculty/Staff[Year]

Graduated / Admitted)□ Former Employee□ Other Related Party (□ Corporation / Group
Donation
representative
Title/Name

Corporation/RequiredGroup Name

Address(Reading in kana)Title / Name
Person incharge

Address
Telephone number

E-mail(Insert a tick in the relevant box)

□ Alumnus(Department

Relationshipwith Gunma
University

Faculty, Department / School[Month]□ Family of Alumnus[Year]

Graduated / Admitted)□ Family of Current Student(Alumnus / Current Student Name
Department[Month]□ Other Related Party (Faculty, Department / School[Year]

Graduated / Admitted))
Continued on backRequired]Amount
Donatedyen

Paymentform□ I/we have a payment form
□ I/we do not have a payment
form, so please post one* We request a minimum 1,000 yen per donation from individuals, or a minimum 10,000 yen donationfrom corporations/groups.

□ Projects that contribute to support for students with their studies (projects to
support students whose financial situation makes it difficult to study)

Required□ Projects related to overall university operation
Donation Purpose□ Projects that contribute to the spread and development of heavy ion
radiotherapy(Please select one.)□ Projects that contribute to support for research, etc. for students, etc.
□ Projects to host or support students or researchers from Ukraine□ 150th Anniversary project* If no purpose is specified for the donation, it will be used for projects related to overall university operation.
* Donations from individuals are eligible for income tax donation deductions, so income tax deductions can be taken
when filing tax returns. In particular, donations for projects that contribute to support for students with their studies
or for projects that contribute to support for research, etc. for students, etc. are now also tax-exempt, which meansthat the more advantageous method can be selected after comparison with the income tax deduction.

Required

Permission for namepublication□ I/we allow publication□ I/we do not allow publication

Donation amountpublication□ I/we allow publication□ I/we do not allow publication＊ Donation amounts will be published on the University's website, PR materials, and elsewhere.

Optional

Message forGunma University

Permission for publicationof message on website, PR
materials, and elsewhere

Optional□ You may post both my/our name and message□ You may post only the message (the name will be shown as “Withheld”)□ You may not post either

SpecialRemarks
Other* If you prefer to pay your donation in installments, please let us know the period and amount of each payment.
We will send you a bank transfer form each time.
* Personal information received from donors will only be used for Gunma University Fund operation and office work. It
will not be used for any other purpose. In addition, Gunma University complies with the Act on the Protection ofPersonal Information and manages donors' personal information appropriately in accordance with the National
University Corporation Gunma University Personal Information Protection Regulations and other relevant regulations.

Inquiries
Fund Unit, General Affairs Section, General Affairs Department, Gunma University
Address: 4-2 Aramaki-machi, Maebashi City, Gunma, 371-8510
Tel.: 027-220-7018
E-mail: kikin@ml.gunma-u.ac.jp