Proxy visitation request form

Please select the organization to which you would like to request a proxy visit (required)
—以下から選択してください—Tsuno ShrineKirishima higashi ShrineAratate ShrineConsult

Please select your prayer (multiple selections allowed)
worshipFamily safetyProsperous businessThank God for God's gracenational securitytroublesomecar coverhealthdiseasegood matchEasy deliveryChildhoodEntertainmentAchievement of your wish

Please fill in the address to which you would like us to send your sacred items (your address)

Postal Code (required)

Address (required)
Please provide your full address, including the county seat, building name, and room number.

Please fill in your name, furigana, date of birth, and contact information

Your name (required)

Furigana of your name (Japanese only)

Date of birth (Western calendar year)
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E-mail address (required)

Re-enter email address (confirmation)

Contact phone number, cell phone acceptable (required)

Please enter your message here

1. A message of completion of transmission is displayed at the bottom.
2. The same content will be automatically sent to the above e-mail address.Please use the domain "ks-wish.jp" in a state where it can be received.