Contact Information
Full Name
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First Name
Last Name
Organization Name
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Contact Phone Number
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Contact Email
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example@example.com
Address
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Street Address
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State
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History of Relationship to The Equity
Nearest Equity Location
*
Please Select
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Alma, IL
Altamont, IL
Dieterich, IL
Effingham, IL
Farina, IL
Farmersburg, IN
Galton (Arcola), IL
Greenville, IL
Horace (Paris), IL
Lovington, IL
Marshall, IL
Montrose, IL
Pana, IL
Robinson, IL
Saint Rose, IL
Stewardson, IL
Strasburg, IL
West Liberty, IL
Has your organization received a donation from The Equity in the past?
*
Yes
No
Is your organization or employees/volunteers of your organization customers of The Equity?
*
Yes
No
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Event Information
Event Date
*
-
Month
-
Day
Year
Date
Deadline for Response
*
-
Month
-
Day
Year
Date
Type of Donation
*
Monetary
Product
Other
Will specific mention be made of support?
*
Yes
No
How will the donation be utilized?
*
More Information about the event:
*
Event Flyer
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