Donation Form
Please fill out this form and return it by e-mail (debbie@cambodiaschools.com) or FAX (03-3486-6789) to Debbie Krisher-Steele, Vice Chair, by Friday, March 18, 2016.  
Thank you very much for your generosity!

Family Name:

	First Name:	
Donor Name (as it should appear in the program):

	E-mail:	
Telephone Number:
	Fax:	
Mobile phone:	Website:
	
Cash Donation of _____________________________yen/ US dollars
Other Donation (include description, restrictions, expiry date or blackout periods)

	

Specific Information About the Donation

Item 1:
	
Quantity:
	Fair Market Value:	
Description (maximum 150 words)/Expiry/ Conditions: (details)

	
Item 2:
	
Quantity:
	Fair Market Value:	
Description (maximum 150 words)/Expiry/ Conditions: (details)

	

Please deliver goods by  April 1, 2016 to

Debbie Krisher-Steele
Hiroo Garden Hills Tower I, Apartment 306
4-1-15 Hiroo Shibuya-ku, Tokyo (150-0012)

Please call or e-mail ahead of time so I will not step away:

Tel: 080-2033-2219
Mobile:080-2033-2219
debbie@cambodiaschools.com

For queries, please do not hesitate to contact me.

Thank you in advance for your generosity in supporting World Assistance for Cambodia!