"THRIVE AT HOME" Global Grant Commitment Form • GG-2577960

"THRIVE AT HOME" Global Grant Commitment Form • GG-2577960

For Use by Clubs and Individuals
ROTARY CLUB - This is being submitted on behalf of a Rotary Club and represents the formal commitment of that Club to support this grant (President or appointed other will sign).ROTARY DISTRICT - This is being submitted on behalf of a Rotary District and represents the formal commitment of the District to support this grant (authorized individual to sign).INDIVIDUAL ROTARIAN - This is being submitted by an individual Rotarian who is committing to support this grant attributed to, OR independent of a Rotary Club. If attributed to a Rotary Club, please list Club and District. If not, leave blank. (Individual will sign.)FOUNDATION OR COMPANY - This is being submitted on behalf of a Foundation or Company to support this grant. (Authorized representative will sign.)OTHER INDIVIDUAL - This is being submitted by an individual who is committing to support this grant by providing funds to a Rotary Fundraiser for matching funds or where most needed. (Individual will sign.)
Total Commitment Amount This Form*
Amount, no $ or comma
Signature Required - Name of Signer*

First NameLast Name
Signer Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name of Rotary Club and District Number

Rotary Club District
Name of Rotary Club and District Number*

Rotary Club District
District Number *
Enter District Number
Name of Individual Supporter*

First NameLast Name
Name of Non-Rotarian Organization, Foundation or Company*
Name of Best Contact*

First NameLast Name
Email*
example@example.com
Best Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address of Organization or Individual*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SOURCE/AMOUNT - Please fill in all that apply.
1. GENERAL FUNDS of the Rotary Club raised by member assessments or general fundraisers conducted by the Rotary Club
$ Amount
My future contribution will be made payable to the International Sponsor, the Villa Park Rotary Club FoundationMy future contribution will be made payable to my ClubMy future contribution will be made payable to my Club's Charitable FoundationMy future contribution will be made payable to the associated Rotary DistrictMy future contribution will be made payable to The Rotary Foundation
List of Member Names and Amounts
Total Amount by Individual Rotary Club Members
$ Amount
3. GENERAL PUBLIC contributions designated to this grant.
$ Amount
4. ORGANIZATIONAL CONTRIBUTIONS designated to this grant. This includes: non-individual supporters, corporate sponsors,governmental agencies, non-Rotary foundations, other non-governmental organizations and made payable to this Rotary Club or Club Charitable Foundation, to the associated District or to The Rotary Foundation.
$ Amount
Contributing Organizations
Thank you for sharing your Pledge information with us and how we may contact you to submit your committed funding upon grant approval.
Signature

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