*all fields marked with an asterisk must be completed.

Organization Name:

*Address Street 1:  

Address Street 2:

*City:  ,  *State:      *Zip Code:  

*Primary Contact Name:  

Secondary Contact Name:

*Phone Number:  

*Email Address:

Are you a 501C-3 Organization? Yes     No

*Organization Type (choose one of the following):Non-profit Service Organization
School
Church/Religious Institution
Social Club
Other

*Please give us a description of what your organization does:
 

*How many members, supporters, parents, etc. are involved in your organization? Under 50
50 - 200
200 - 500
500 or more

*Is the address for your quarterly payments the same as the address listed above? Yes     No

If No, please provide us with the address:

Organization Name:

Address Street 1:

Address Street 2:

City: ,  State: Zip Code:

Check this box if you have read the terms.