Designated Donation FormPersonal

Endeavor Project

To: National Cancer Center (NCC)

We donated the money to support the above project with consent of National Cancer Center

Donation Acceptance Policy Article 3-1 (see back page please).

Date:

1.Name
2. Post Address
3. Phone Number
4. Amount (JPY)
5. Payment / □Online □BK Transfer
6. Disclosureof Name in / National Cancer Center PR brochure □YES □NO
NamePlate in National Cancer Center Research Institute* □YES □NO
7. Research Events / □I would like to receiveinvitation mails to eventsarranged by NCC.
E-Mail Address:
□I would NOT like to receiveinvitation mails to events arranged by NCC.

*for over ￥100,000 of donation

Please send this form to:

National Cancer Center

Post Address：5-1-1, Tsukiji, Chuo-ku, Tokyo, Japan 〒104-0045

Fax：81-3-3542-2545

E-mail：ncckifu @ ncc.go.jp

BK Account Details:

For Overseas Residents

TheBank of Tokyo-Mitsubishi UFJ, Ltd.Tokyo Government and Public Institutions Business Office

Branch Number: 300 SWIFT CODE:BOTKJPJT

Account Number:0021563 Name of Account:National Cancer Center

For Domestic Residents

The Bank of Tokyo-Mitsubishi UFJ, Ltd. Umikaze Branch

Account Number:5515047 Name of Account: National Cancer Center Hospital

The receipt by National Cancer Center will be sent to the donner in several weeks after confirmation of the payment.

Article 3-1 (Criteria for Accepting a Donation)

1The Center cannot accept any donation from a person who intends to donate on the condition that:

(1)any asset acquired with the donation will be transferred or loaned to the donor free of charge;

(2)any intellectual property right, etc. generated from research funded by the donation will be transferred or made available to the donor;

(3)the donor will audit the account on the use of the donated money or goods;

(4)other than the preceding items, the donor will claim any other form of consideration against the Center; or

(5)the donor, after proposing to donate, can choose to cancel part or all of the donation, etc.