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Donation Request

Contact Information

Company/Organization*

Name*

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Event Information

Event Name*

Is the speaking engagement for a 501(c)3 tax-exempt organization?

Yes No

Event Date & Time*

:

Event Location

Address Line 1

Address Line 2

City

State

ZIP Code

Description of and reason for event*

Donation Information

All requests must be submitted 30 days prior to event date. In order for your request to be reviewed, all information in this form must be completed in its entirety. We will contact you as soon as we can after receipt and review of your completed request form.

How will the donation be used?

Auction Door Prize Raffle

Other:

Please select

Is the donation for a 501(c)3 tax-exempt organization?*

Yes No