Organization Name*

Organization Address*

Street Address
Address Line 2
City
State
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 irs.gov/w9 for current form and instructions.

Is your organization a registerd non-profit, 501(c)3? Yes No

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*

Website

Where is your Local Rouses?*

Description of Event

Please tell us which focus area your request falls under:
Hunger Relief Neighborhood Enrichment Health Youth and Disabled Culinary Education
Other

Age Group Served: (Check all that apply)
Under 5 5 - 18 19 - 29 30 - 60 Over 60 Pets specific

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

Yes No

•	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:

Rouses Gift Card	: Amount
Water Donation	: Amount
Sponsorship	: 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?

EVENT INFORMATION

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:

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