Service Application Form

Date (YYYY/MM/DD) for Service

Time 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

Gender (Female / Male / other)

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

Email

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 donation fee (Otamagushiryo)

Please donate a minimum of $100 per service 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

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Event Email Sign-up

Additional Name(s)

Service donation fee (Otamagushiryo)

Event release Subscription

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May the Kami-sama be with you!