Contribution Application

Contribution Application
Eagle Mine actively participates with local organizations and supports projects that promote long-term mutual benefits to the community.

To request funds from Eagle Mine, please review Community Assistant Guidelines and complete application below.

The following areas are excluded from consideration:
- Private companies seeking funding for business activities
- Capital works projects (bricks and mortar)
- Religious organizations
- Government bodies traditionally funded by government
- General operating expenses/travel/accommodations
- Individual community members
- Individual sports teams
- Political candidates
Today's Date*

MonthDayYear
Date
Name of Organization*
Name of Event/Program *
Date of Event

MonthDayYear
Date
Contact's Name*

First NameLast Name
Contact's Phone*
Contact's Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Brief description of organization

0/500
Brief description of event/program/project

0/1000
Brief description of expected outcomes

0/500
Brief description of the population served and where they are located

0/500
Amount requested*
Percentage of total budget
Are other funding sources secured?

YesNo
Have you received a contribution from Eagle Mine in the past?

YesNo
Brief description of any sponsorship packages
Upload sponsorship form (if any)

Cancelof
List of board members and their affiliations (if any)
Is the requesting organization a non-profit?

YesNo
Proof of qualifying non-profit status, including a tax exempt determination letter from the Internal Revenue Service (501c3).

Cancelof
Electronic Signature*
I verify that the information submitted in this form is true and accurate, to the best of my knowledge.*

Yes
Should be Empty: