Organization Name

Mailing Address

Street Address

Address Line 2

City

State / Province / Region

Zip/Postal/Code

Country

Phone

Website (if available)

Federal Tax ID # (if applicable)

Mission Statement

Contact Name

First

Last

Title

Contact Email Address

Phone

Donation or Sponsorship Request

Date of Event

How many people will be attending the event?

How will you recognize EnergyUnited's participation in this event?

Has this organization received a donation or sponsorship from EnergyUnited in the past 12 months?

If yes, when?

Amount Requested

How will you use the donation or sponsorship from EnergyUnited?

Please attach any additional materials (logo, flyers, posters, brochures) that represent this nonprofit, organization, or event.

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