Organization / Group Name:*

Address*

City:*

Postal Code:*

Contact Name:*

Contact Title:

Contact Email:*

Contact Phone:*

Are you fundraising for your group or another group? If another group, please specify:*

Event Name:*

Event Date:*

Donation Deadline:*

How will the donation be used?

Silent Auction

Raffle

Live Auction

Other

Other - Please specify: