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Online Application Form

Organization Name:

Organization's Taxpayer Identification Number (TIN):

Organization's Address:

Street or PO Box:
City:
State:
Zip:

Is this organization designated by the IRS as a 501(c)(3) non-profit or tax-exempt organization?
Yes No

Community Served:

Amount Requested: $

Will these funds be used to provide direct benefit in the area(s) of education, agriculture, environment, health and social services, public safety or fighting hunger and poverty; or to directly support a cultural or heritage event in the community?
Yes No

Will these funds be used to support a service, fraternal or veterans organization; religious activities of a church or religious organization or political action or lobbying?
Yes No

Will these funds be used to aid a single individual or family?
Yes No

Will these funds be used to support a participatory fund-raising event, such as a team walk, golf tournament or charity banquet; or to support an endowment or the overhead costs of fund-raising activities?
Yes No

Will these funds be used to support a sports team, an individual athlete or a competitive league or competitive event?
Yes No

Does this organization receive funding from the United Way?
Yes No

Describe how the funds will be used to benefit the community and who will benefit.

Please provide a brief description of the organization's primary activities.

You may attach additional files to support your application request. (Word or PDF only)

Enter your name & contact information:

Title:
Name:
Phone:	() -
Email Address:

Are you a Perdue associate or does this organization have an affiliation with Perdue associates?
Yes No

Title:
Location:

Describe the affiliation between the charitable organization and Perdue.

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