Operation Round Up Application

Name of Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

E-mail Address

Phone Number

Contact Person Name

Contact Person Organizational Title

Is the organization requesting funding exempt from payment of income tax?

Yes - A copy of the letter (Form 501 (c) 3) from the Internal Revenue Service must be submitted.

No

Form 501

One file only.
100 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip.

Number of individuals, families, or groups served in Roughrider Electric Cooperative's service area last year:

Does your organization/agency serve outside of Roughrider Electric Cooperative's service area?

Yes

No

Please provide information on numbers of individuals, families or groups served and their location.

Please state the purpose of the organization/agency's request: (Include amount requested and specifics of how funds will be used.)

List other sources of funding for use or request as described in the above.

How are your organization/agency's programs measured for effectiveness?

Reference One

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Reference Two

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Reference Three

Name

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Authorization

Yes, I understand and accept this agreement. The information contained in this statement is for the purpose of obtaining funding from the Roughrider Electric Charitable Foundation, Inc. on behalf of the undersigned. The undersigned understands that the information provided is true and complete and warrants that the information provided is true and complete and that the Roughrider Electric Charitable Foundation, Inc. may consider this statement as continuing to be true and correct until a written notice of a change is provided. The Roughrider Electric Charitable Foundation, Inc. is authorized to make all the inquiries they deem necessary to verify the accuracy of the statements made herein.

Latest

Operation Round Up Application

Reference One

Reference Two

Reference Three

Hazen Office

Dickinson Office