* Organization
     
* Business Address
     
* City
*State *Zip
     
* Phone Number
 ( ie. 123-456-7890 ) *Fax Number  ( ie. 123-456-7890 )
     
* Email Address
*Fed Tax ID#  9 digits only
     
 

Please describe the services your organization provides for the community.

 
     
     
  I/We certify that the above statements are true and correct. I/We agree to comply with all
applicable donation laws, guidelines and requirements.