APPLICATION FOR DONATION ORGANIZATION AND/OR AGENCY

Name of Organization*

Address (Street or P.O. Box)*

City*

State*

Zip Code*

Contact Person Name*

Contact Person Title*

Contact Phone Number*

Contact Email Address*

Is the organization requesting funding, exempt from payment of income tax? *

Yes No

If yes, please attach a copy of an IRS letter indicating your organization's 501(c)3 status.*

(pdf, doc, docx, jpg, jpeg, png, gif)

A copy of the financial statement(s) for the most previous year should be provided.

(pdf, doc, docx, jpg, jpeg, png, gif)

Have you previously received funding from Operation Round-Up? *

Yes No

If yes, please list the date and amount you received.*

Describe the purpose for the funds requested. Please include the amount requested and specifics of how the funds will be used. *

List other sources of funding being used in the request described above.

Is your organization served electric power by First Electric Cooperative? *

Yes No

If so, do you authorize permission to enroll your organization’s account(s) in Operation Round-Up, if awarded funds? *

Yes No

Name of Organization*

Representative's Signature (type your name as you would sign it)*

Operation Round-Up Enrollment Form for Donation Organization and/or Agency