Jimmy Madison's Restaurant Outreach

E-mail*

Name of Organization*

Organization's 501(c)3 if applicable

Information on the Organization*

Request*

Dollar Amount Request*

How will the money be used?*

Where will the money be used*

Event Date*

Contact First Name*

Contact Last Name*

Address*

City*

State*

Zip

Do you pledge that the donation will not discriminate against anyone as prohibited by law?*

Yes

Other information not included above