Dollars for Doers and Brats for a Cause
STEP 1: MEMBER INFORMATION (To be completed by you, the Johnsonville Member. Please print.)
Name: / Home Address:
Work Location: / City:State:Zip:
Work Phone: / Home Phone:
Work E-mail: / Home E-mail:
INFORMATION ABOUT YOUR REQUEST
Name of Organization*:Organization Focus Areas: (Check all that apply)
Education
Community & neighborhood development
Human services and health / What are you requesting? (Check all that apply)
Dollars for Doers $250 (20 hours)
Dollars for Doers $500 (40 hours)
Fundraiser Participant $50 (run, walk, bowl-a-thon,etc)
Brats for a Cause – 2 cases** (Provide details below)
Name of event:
Date of event:
Total number of hours volunteered between January 1 of the current year and today’s date:
At least 20At least 40
What specific duties did you perform?
How will these funds be used to benefit the organization?
* Please include an “About Us” section describing the mission, objectives, and activities that the organization engages in or provides. This can often be found and printed off the organization’s website.
** If your application is accepted, you will be responsible for picking up product from the Member store and delivering it to your organization. You will receive additional instructions if your application is approved.
I certify that the information in this application is true and accurate to the best of my knowledge.
Signature: / Member Number:Once you complete Step 1, give the form to a representative at your organization to complete Step 2.
STEP 2: ORGANIZATION INFORMATION (To be completed by the organization you support.)I confirm the following:
The organization described below is a nonprofit group determined to be tax-exempt under 501(c)3 of the Internal Revenue Code.
The volunteerism described in Step 1 is true and accurate to the best of my knowledge.
Organization Name*: / FEIN Number:
Address: / City: State: Zip:
Representative Name: / Phone:
Title: / E-mail:
Signature: / Date:
* as it appears on 501(c)3 IRS determination letter
STEP 3: SUBMIT APPLICATION (To be completed by you, the Johnsonville Member.)Return this completed application form with a copy of a flyer for your fundraiserto:
Electronically:
Hard Copy: Kerri Vogel -GHQ
Please submit your applications three weeks prior to your event. If you have an emergency situation,
please contact Kerri Vogel at 920-453-7409.
Return this completed application form
with a copy of your W-9 to:
Electronically:
Hard Copy: Kerri Vogel -GHQ / STEP 4: CAREVILLE AUTHORIZATION
(To be completed by the Careville Team.)
Date Received: / Date Approved:
Amount: / Cost Center: