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

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 other contributors and amount of donation/sponsorship

Contributor

Amount

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

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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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PERMOBIL FOUNDATION SPONSORSHIP APPLICATION

ORGANIZATION INFORMATION