Fundraising Request Form

Please submit your application for consideration no later than 4 weeks prior to your event.

Date of Proposed event:*
Date Format: MM slash DD slash YYYY
Full Legal Name of Third Party (Organization or Group Name):*
Third Party Address*
Street Address Address Line 2 City State ZIP Code
Website
Name of Proposed Event
Contact Person*
Title
Email*
Phone*
Fax
Description of Event
Location of Event
How will you generate money?
Donation Structure (describe basis of donation to be made to the Komen Affiliate [i.e., flat donation, event admission, pledges, guaranteed minimum donation])
Publicity/Promotion: (how are you going t o get the word out about your event - flyers , radio, website, TV )
(All proposed materials utilizing Susan G Komen Miami/Ft. Lauderdale Affiliate logo must be pre-approved prior to use) Applicant understands that approval must be granted by Komen and a Letter of Agreement must be executed by the parties before applicant can promote the proposed event. The Miami / Ft. Affiliate of Susan G Komen shall not be liable to any vendor or other third party for any fees, costs, or payments of any kind associated with the event, and applicant agrees to indemnify and hold harmless the Komen Miami/Ft. Lauderdale Affiliate against any such claims by third parties or vendors for said fees, costs, or payments.
Signature