1 Organization Information2 Donation Details3 Signature Organization Name*Does your organization have a 501(c)3 status?*YesNoContact Person*Email* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*What is your website?Are you a current Blackfoot customer?YesNo Donation DetailsNext, tell us a bit more about your donation request.What is the purpose of your request?*Event Date(s) and Time*Event Location*What is the donation amount requested?*What is the deadline for sponsorship commitment?*Who should the check be made payable to?*How will the donation be used?*Has Blackfoot sponsored this event before?*YesNoPlease describe who directly benefits from the donation requested.Will this donation be matched with other funds or sponsors (what level)? Blackfoot Telecommunications Group and Blackfoot Telephone Cooperative reserve the right to deny any request or honor a partial amount of the request without stating any reasons. Electronic Signature*Please fill in your name below to electronically sign your application. By doing so, you are acknowledging that you are a representative of the organization, and all information entered on the form is accurate to the best of your knowledge.Date* Upload Proof of Non-Profit Status*You indicated your organization is a non-profit. Please upload documentation that provides proof of your 501(c)3 status.Upload Your W-9If funding is approved, a completed Request for Taxpayer Identification Number and Certification (IRS Form W-9) will be required. You can upload and submit your W-9 now to expedite your request. If you need the W-9 form, please visit http://www.irs.gov/pub/irs-pdf/fw9.pdf. NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.