Organization information
Name of organization
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Organization website (can be a Facebook page)
*
Are you a 501c3 organization?
*
Yes
No
Contact information
Contact name
*
Contact email
*
example@example.com
Contact phone number
Deadline to receive donation
*
-
Month
-
Day
Year
Date
(
See Connexus' deadlines for requests
)
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Please describe the impact of this donation by indicating the number of individuals served, including any relevant demographic information (e.g. counties served, populations, etc.).
*
Attach documentation that demonstrates impact (e.g. annual report, etc.)
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We support nonprofit organizations that serve our service territory and whose goals align with the following initiatives. Please select the initiative that best aligns with your organization's mission. (select only 1)
*
Youth
Education
Community service
Environment
Request type (select only 1)
*
Gift basket
Monetary donation
Event sponsorship
Does your organization serve Connexus members?
*
Yes
No
See Connexus service territory
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Gift baskets
Event theme
*
Event date
*
-
Month
-
Day
Year
Date
Event website
Upload event flyer
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Monetary donations & event sponsorships
Amount requested
*
Event date
-
Month
-
Day
Year
Date
Event website
Upload additional information to support your request
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EIN/Tax ID
*
Attach W9
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Please verify that you are human
*
Submit
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