Donation Request Application

Please fill out the Organizational Support Application below at least 3 weeks in advance of your event date. Thank You. 
 

*Organization Name:
*Contact Email Address:
*Contact Name:
*Contact Phone:
*Organization Address
*Organization City
*State	(Select) Alabama Alaska American Samoa Arizona Arkansas Armed Forces Americas (except Canada) Armed Forces Europe, Canada, Africa, Middle East Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
*Zip Code
Is This Donation Request in association with a particular event?	Yes
If so, when is the event?	[None]
Please give the name of the event and a brief description:
*Type of Request (i.e. Product, Monetary)	Product Monetary Time
*How will this donation be used?
Is your organization an IRS recognized Not For Profit Organization? (i.e. 501C3)	Yes
Has this organization received a donation or reduced pricing from us in the past 12 months? (Please be certain this answer is correct.  Non disclosure may result in permanent program exclusion)	Yes
If yes, what and when?
Please give additional comments, or details we may need to know:

 
By submitting this electronic form, I hereby certify that:  

a) The information in this application and supporting documents are correct to the best of my knowledge.
b) The Internal Revenue Service determination has not been revoked, cancelled, or modified.
c) Funds or goods will be used only for the projects outlined in this application.

*I have read and hereby agree with the terms and statement above.   I Agree  

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