Community Engagement

FUNDING REQUEST FORM
For tax purposes we require that the application be completed in its
entirety prior to authorizing a donation.

Fields marked with an * are required.

* Name of Organization:
* Organization Goal and Purpose:
* EIN#:
* Address:
* Name of Person Completing this Form:
* Telephone Number:
* Email Address:
* List Board President and Members:
* Have we donated to your organization in the past? Yes No
   

FUNDING TYPE:


* Contribution will be used for (please check one of the following and enter description if applicable.)
General Fundraiser:
Scholarship Fund:
In-kind request and type:


EVENT or PROGRAM:


*Event Name:
*Event Date:
*Event Location:
*Number of people attending event:
*SPONSORSHIP COST or AMOUNT SUGGESTED:


DONOR RECOGNITION:


*Please describe advertising plan and recognition that donors receive:

As a recipient of a 2016 charitable contribution, please provide the following information about the individuals serviced by this event.
NOTE: Each section below is mandatory to fill. If program specific data is not available, please provide demographic information for the clients served by your agency. Each section should total 100%. Please use the 'Unknown' box if data is not available in order to make it 100%.

ETHNICITY: GENDER:

Asian/Pacific Islander

Female

Black/African American

Male

Latino/Hispanic

Unknown

Native American

White/Caucasian
SEXUAL ORIENTATION:

Multi-ethnic
Lesbian/Gay/Bisexual/Transgender

Unknown

Heterosexual

Unknown
DISABILITY:
Of Persons with Disabilities  

Unknown
 
 

*Number of people anticipated to be served in your program/agency in 2016