Ceremony Application Form 202010

ご祈祷申し込み書

Gokitō Request Form

ご祈祷料（御玉串料）は、お一人＄100〜（送料別）お納めください。

Gokitō fee donation is minimum $100 per person plus shipping fees.

ご祈祷には、お守り（１体）が含まれています。

You will receive one Charm.

ご祈祷料（御玉串料）は、PayPalでも受付けています。QRコード、または、下記リンクをご利用ください。

We accept ceremony fee donations (Otamagushiryō) via PayPal.

Please use the QR code or this link:

https://www.paypal.com/us/fundraiser/charity/3405572

御朱印や写真を貼って記録を残せる

人生の節目アルバム　お詣りの記録（御初穂料20ドル）

をご希望の方はお申し出下さい。

Please let us know if you would like to obtain

"Visit Record and Milestone Album" ($20)

which you can keep your Goshuin and photos.

※ご記入いただいた個人情報は、法律で定められた場合を除き、

当神社のご祈祷・運営管理の目的にのみ利用させていただきます。

※Information submitted into this form will be used only for Gokitō ceremony and Shrine administrative purposes.

It is not sold or shared. Contact us to have your information removed.

Date (YYYY/MM/DD) for Ceremony you are available

Time for Ceremony you are available

Name Reading (Please write your name in Japanese if Possible)

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth (MM/DD/YYYY)

Age

Gender (Female / Male / other)

Please write your request for ceremony as detailed as possible.

For recovery from illness/injury: Please write name of affliction, how long the individual has been suffering, the name of doctor and hospital, the day of surgery (mm/dd) etc...

Phone/Cell number

Additional Name(s)

Name of Companion(s) (i.e. parent, partner, etc. )

Their name(s) may be read out loud in the service.

Companion 1

Relationship (i.e. parent, partner, etc. )

Companion 2

Relationship (i.e. parent, partner, etc. )

Companion 3

Relationship (i.e. parent, partner, etc. )

Ceremony donation fee (Otamagushiryo)

Please donate a minimum of $100 per ceremony plus shipping when applicable.　　　　　　　　　　　　

We accept donations via check or PayPal. 　

Payable to: Shinto Shrine of Shusse Inari in America

Paypal: PayPal@ShintoInari.org

Please select amount of donations

Other Amount/ Offerings

Event release Subscription

If you would you like to receive information about our events and seasonal Gokitō, please submit our sign-up form.

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ご祈祷申し込み書

Gokitō Request Form

ご祈祷料（御玉串料）は、お一人＄100〜（送料別）お納めください。

Gokitō fee donation is minimum $100 per person plus shipping fees.

ご祈祷料（御玉串料）は 、PayPalでも受付けています。QRコード、または、下記リンクをご利用ください。

We accept ceremony fee donations (Otamagushiryō) via PayPal.

Please use the QR code or this link:

https://www.paypal.com/us/fundraiser/charity/3405572

御朱印や写真を貼って記録を残せる

人生の節目アルバム お詣りの記録 （御初穂料20ドル）

をご希望の方はお申し出下さい。

Please let us know if you would like to obtain

"Visit Record and Milestone Album" ($20)

which you can keep your Goshuin and photos.

※ご記入いただいた個人情報は、法律で定められた場合を除き、

当神社のご祈祷・運営管理の目的にのみ利用させていただきます。

※Information submitted into this form will be used only for Gokitō ceremony and Shrine administrative purposes.

It is not sold or shared. Contact us to have your information removed.

Additional Name(s)

Ceremony donation fee (Otamagushiryo)

Event release Subscription

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ご祈祷料（御玉串料）は、PayPalでも受付けています。QRコード、または、下記リンクをご利用ください。

人生の節目アルバム　お詣りの記録（御初穂料20ドル）