Organization Name*

Representative Name*

Website for the Charity or Representative

Is your organization a government-sanctioned non-profit?* Yes No If yes, what is your tax classification code or IRS code (EIN number)?

Contact First Name*

Contact Last Name*

Contact Job Title

Contact Phone Number*

Contact Email Address*

Street Address*

City*

State*

Provide a brief description or summary of your opportunity. Please give us an overview of your fundraising event.

Is there media coverage associated with this request? Yes No If yes, indicate which types of media or broadcast exposure Newspaper TV - Local TV - National Internet, Webcast Radio

Total estimated on-site audience for event

Please describe the general atmosphere for the event (include what is happening at or around the event (i.e. vendors, booths or other retailers).

Are there promotional opportunities for Viaero Wireless? Yes No If yes, please list promotional opportunities

Date of event* to

Please provide any other information that may be useful