Employee Sponsored Request Application – North

Preference is given to programs that serve multiple communities in our service area.

Employee Name

Office Location

Name of Organization

Street Address

City

State

ZIP Code

Contact Person

Phone Number

Is your organization a 501(c)(3) registered non-profit organization?

Yes No

Please select Community Program

Please describe how the funds will be used to support the Community Program indicated above.

Amount of Gift Requested

How will this gift be used?

What is your relationship to the organization?

Are employees needed to support the event?

Yes No

If employees are needed, please explain.

Please attach W-9 Form

Supporting Documents