PERMOBIL FOUNDATION SPONSORSHIP APPLICATION

PERMOBIL FOUNDATION SPONSORSHIP APPLICATION
ORGANIZATION INFORMATION
Name of Organization/Agency:
Federal ID #:
Address:
City:
State:
Zip Code:
Contact Name:
Title:
Email:
example@example.com
Phone #:
Does your organization/agency have a 501(c3) tax-exempt status:

Yes No
Primary contact or relationship at Permobil:
Have you previously received funds from Permobil?

Yes No

If yes, please provide additional information (date, funding amount, brief purpose of donation)

	Date	Amount	Purpose
1
2
3
4

Provide a brief overview of your organization's mission, date founded, national or local organization, etc:
DONATION REQUEST: request must be a minimum of 60 days prior to your event

Please include a written narrative of your request that includes the following (limit 3 pages including itemized budget):
- Details about of your organization (mission, accomplishments, etc
- What are the key objectives/purpose of your request
- If this request is for a college scholarship please include: Name of col lege, uni versity, or tec hnical school; expected date of enrollment; course of study; and current GPA
- Who would benefit from your program
- If sponsorship benefits are involved include all levels/opportunities of support
- How will your organization use the funding (please include a itemized budget to support)
Briefly describe an overview of your request including date of event (limit to 3-5 sentences):

Amount Requested

	Amount
Total Requested
Total Funding to be raised
Funding date requested by
Funding from other sources

Please list all levels of Sponsorship available

Please list other contributors and amount of donation/sponsorship

	Contributor	Amount
1
2
3

Please ensure the following are included with your proposal:
- Completed application
- Written narrative of your request including itemized budget
  and all levels of sponsorship opportunities (limit 3 pages)
- Copy of 501(C 3) IRS Approval
- C urrent form 990 or financial statement
- Current list of Board of Directors
- For additional information please email: Info@permobilfoundation.org
Written Narrative

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Cancel of
501c3 IRS Approval

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Cancel of
Organization Financial Statement

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Cancel of
Organization Board of Directors List

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Cancel of
Sponsorship Levels (you must complete the spsons

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Cancel of
Other

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Cancel of
Certification and Acceptance: I certify that information contained herein is true and complete and accept the obligation to comply with the terms and conditions if the request is awarded as a result of this application. I further certify that the organization named above currently has tax-exemption under the Internal Revenue Service Code Section 501(c3), that the Organization’s IRS determination letter has not been revoked. Non-Discrimination: The Permobil Foundation will not make contributions to groups that discriminate on the basis of race, color, religion, gender, mental or physical disabilities, sexual orientation, national origin, age, citizenship, veteran/reserve/national guard status or other protected status; partisan political organization; or groups limited to members of a single religious organization.
Signature of Representative

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Title
Date

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Date
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PERMOBIL FOUNDATION SPONSORSHIP APPLICATION

ORGANIZATION INFORMATION