Organization Name*
Organization Address*
Street Address
Address Line 2
Zip Code
Organization Phone #* - -
Organization Tax #* -
Attach your W-9 here:
 • Attach ONLY your W-9 here. Do not attach any other files other than the information request. Incomplete requests will not be considered.
 • Need a blank W-9 for to complete? Visit for current form and instructions.

Is your organization a registerd non-profit, 501(c)3?
      If yes, Attach your 501(c)3 designation here:
 • Attach ONLY your letter from the IRS showing your non-profit status confirmation. Do not attach any other files other than the informaton requested. Incomplete requests will not be considered.
Contact Person* First Last
Contact Phone #* - -
Contact Email*
Where is your Local Rouses?*
Description of Event
Please tell us which focus area your request falls under:
Age Group Served: (Check all that apply)
ELIGIBILITY. Does your request fall into any of the following categories?
   • Individual Needs
   • Professional Seminars/Conferences or Employee Recognition
   • Taxpayer-supported agencies
   • Sporting events or teams
   • Political
   • Trips and travel costs
   • Scholarship or fellowship programs
   • General operating, advertising, or capital campaigns
   • Thrid parties
   • Agency or event outside our areas
   • Solicitation
 • If your request falls into any of the above categories, we appreciate your reaching out to Rouses; however, per our guidelines, our charitable donations are generally not to be used toward those activites.
I/We would like to request a:
    : Amount
    : Amount
    : Amount
Describe your request- how will donated funds or product be used:
Provid 2-3 sentences regarding your organization, including a summary of mission and objectives:
Project Description:
How will our store be recognized for participating?
Important: If you are submitting a request for an event, please ensure that it is at least six (6) weeks prior to the start date. Event requests submitted fewer than six (6) weeks prior to the start date will not be considered.
Event Date* / /
Anticipated Attendance*
Event WebSite*
If we have helped with this event before, please explain prior participation: