Organization(Required) Contact Name(Required) First Last Mailing Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Amount or Services Requested(Required) Date Donation or Services are Needed (mm/dd/yyyy)(Required) Month Day Year Describe the purpose of the donation: event sponsorship, items needed, services requested, etc.(Required)Describe the value to UEC: logo on program; name at event, tickets to event, etc.(Required)Has UEC sponsored/donated to your organization in the past?(Required) Yes No What and when?(Required) List any additional relevant information/commentsMember Consent(Required) I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today’s date and authorized by me as if I had signed my signature.The above is correct to the best of my knowledge, and if the donation is approved, the goods and/or money will be solely used and expressly for the purpose listed.Member Electronic Signature (Full Name) NameThis field is for validation purposes and should be left unchanged.
