Fundraising Application

Organization Name*
State*
Type of Organization*
- Non-Profit
- Church
- School
- Sports Group
- Other
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Person*
First Last
Phone*
Number of Coupons Requested*
Email*
Date Coupons Needed*
MM slash DD slash YYYY

What day will you need the coupons by?
**Reconciled must be 30 days or less from the date the coupons are received. Checks cannot be held more than 30 days.
Signature
Today's Date*
MM slash DD slash YYYY
Terms & Agreements*
- By typing your name and dating, you are verifying that all information provided is accurate and truthful.