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

This is a Pledge, with no funds due today. It is being collected by the Villa Park Rotary Club, International Sponsor; and Quetzaltenango Rotary Club, Host, for our records and will be included in our "Thrive for All" grant submission as the signer's promise to provide funds to this grant. Thank you for your participation! Please select from the following:

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.

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.

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

2. PLEDGES BY INDIVIDUAL ROTARY CLUB MEMBERS (this helps us keep track of where your contribution will be held):

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