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Fundraising Request Form
Katty Payne
2018-08-06T12:06:01+00:00
Application for Special Event, Benefit, or Promotion
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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.
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