Climb For A Causesm
Please print, then complete and return to: Climb For A Cause, 1512 N. Fremont Street, Suite 102, Chicago, IL 60622. Thank you.
Name of Organization:_________________________________________
Climb For Which Applying To Be Named Beneficiary________________
Date of Incorporation as a Non-Profit Entity:________________________
Federal Employer Identification Number___________________________
Is There Any Legal Action (current or pending) For Which Your Organization is a Defendant or Respondent?________________________
If Yes, Please Elaborate________________________________________
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May Funds Raised For Your Organization Be Earmarked For Certain Uses?________
If Yes, Please Delineate Some Or All Of These_____________________
___________________________________________________________
Please Provide Three Trade References
__________________________________________________________________
__________________________________________________________________
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Please Provide The Names Of Three Individuals Or Entities To Whom Your Organization Has Rendered Assistance, Or Examples Of Benefits Your Organization Has Delivered
_____________________________________________________________
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(please include the following with your Application)
Annual Report Mission Statement Certification of Non-Profit Status
Camera-Ready Logotype Letter of Endorsement Press Releases
If part of a national organization, description of your affiliation with that entity
I hereby affirm that the information I am providing is true and complete, to the best of my knowledge. I understand that the misrepresentation or omission of any material fact may void my Application.
Signed________________________________ Date___________
Beneficiary Organization Representative