* First Name:_______________________________ * Last Name:________________________________
* Email:___________________________________ * Best time to contact:________________________
Address:_______________________________________________________________________________
City:_____________________________________ State:_____________ Zip:_____________________
* Organization:_________________________________________________________________________
* Non-profit corporation number:_____________________________ Date incorporated:____________
* IRS tax deduction number:________________________ Fed tax ID:___________________________
* Your relationship to the organization:____________________________________________________
* Your request:_________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
* Date of event soliciting for:__________________________ * Location:_________________________
______________________________________________________________________________________
* Additional information attached: Yes________ No________
* Signature:____________________________________________________________________________
* Date:________________________________ * Best contact number:___________________________
Fax this form along with any other relative information to 309-272-7287.
