Requested Information Fundraisers are held on Monday, Tuesday or Thursday. Fundraiser applications are approved based on fully completed applications and date availability. Requests must be submitted at minimum 2 weeks prior to requested date.

Name of organization (check made payable to):

Group/Organization name reflected on fundraising materials (your fundraiser coupons):

Street Address (where you would like the check mailed to):

City

State - Choose an Option - AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Organization's Tax ID number (required):

Contact Person Name:

Contact Person Phone Number:

Contact Person E-mail Address:

Please select a date (must be Monday, Tuesday or Thursday): January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

In the event that your first choice is not available, please select a second date (must be a Monday, Tuesday or Thursday): January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Number of people estimated to attend - Choose an Option - 25+ 50+ 75+ 100+

Choose a location: - Choose an Option - Batavia Fairmount Erie Blvd Rochester Cicero Amherst Clarence Liverpool Vestal Cheektowaga Clarks Summit Watertown

Is your organization a qualified 501 (C)3 organization? - Choose an Option - Yes No

If you answered yes, please read and sign this notice: In order to conform with Internal Revenue Code Section 170(f)(8), our organization states that it did not provide goods and services in consideration for this gift. (To sign- please type your name)

How did you hear about our fundraising opportunities?

Please enter additional comments and questions below:

I understand that by signing below, I am authorizing someone to contact me in regards to Fund Raising opportunities with Tully’s Good Times. I also understand that by returning this form, Tully’s Good Times is under no obligation to hold the Fund Raiser. If we agree to schedule the Fund Raiser, the organization that I represent will not hand out Fund Raiser Coupons on the premises or in the parking lot at any time. Doing so may result in cancellation of the event. I give permission to Tully’s Good Times to use my organization’s name and donation amount from the above event in response to media inquires. (To sign- please type your name and date)