Organization Name
*
Name
*
First Name
Last Name
Contact Person's Relationship to Organization
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
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Please enter a valid phone number.
Email
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example@example.com
Amount Requested
Does your organization operate in our service area?
*
Yes
No
Is your organization a 501(c)3 not-for-profit?
*
Yes - please attach form below
No
What will the donation be used toward?
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If for an event, please give details.
*
How will Hilliary Communications be promoted, or the logo displayed?
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