Service Application Form

Date (YYYY/MM/DD) for Service

Time (PST) for Service

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

Sex (Female/Male)

Service Please write your request 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. )

Service fee (Otamagushiryo)

Please donate minimum $50 per service (donations appreciated)　　　　　　　　　　　　　

We accept donations via check or PayPal. 　

Payable to: Shinto Shrine of Shusse Inari in America

Paypal: PayPal@ShintoInari.org

We appreciate it if you cover the PayPal transaction fee.　

Please select amount of donations

Other Amount/ Offerings

Newsletter Subscription

Would you like to receive information about our events and seasonal Gokitō?

Yes! (Please include your email and postal mailing address)

Numeric Field