Fundraiser Registration Agreement 1.) SPONSOR INFORMATIONName of sponsoring organization/individual*Contact Person*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone*Email* Is your organization registered as a charitable organization under the Pennsylvania Solicitation of Funds for Charitable Purposes Act?*YesNo2.) EVENT INFORMATIONName of event/Type of event*Event Location*Date event will start* Date Format: MM slash DD slash YYYY Event Start Time* : HH MM AM PM Date event will end* Date Format: MM slash DD slash YYYY (Donations, including items collected, should be delivered to the Mario Lemieux Foundation within two weeks of this date. Arrangements to deliver donations must be made at least 48 hours in advance of delivery.)Event End Time* : HH MM AM PM Please describe the event and include any fees charged for admission or goods/services and/or items being collected.*Please attach approvals from local authorities and evidence of insurance, if applicable. Drop files here or A Foundation representative may be able to attend your fundraising event - to ask for a representative or materials, please contact Stephanie Spezialetti, Program Manager at 412-281- 3466 or email@example.com at least three weeks before the event. 3.) SIGNATUREI fully understand and agree to comply with the terms outlined in the Foundation’s Community Fundraising Guidelines. I agree to act in a professional manner in conducting the fundraising activity and uphold the integrity and values of the Foundation. I also accept the obligation to remit the funds raised to the Mario Lemieux Foundation within two weeks of the event’s conclusion. Signature*Date* Date Format: MM slash DD slash YYYY This form is due four weeks prior to the proposed event. Completion of this form does not insure approval. Upon approval, you will receive an approved signed copy of the application form for your records. If you have any questions regarding this form or your fundraising event, please contact Stephanie Spezialetti, Program Manager, at 412-281-3466. Mario Lemieux Foundation is a 501(c)(3) organization. The official registration and financial information of the Mario Lemieux Foundation may be obtained from the Pennsylvania Department of State by calling toll free, within Pennsylvania, 1-800-732-0999. Registration does not imply endorsement. This iframe contains the logic required to handle Ajax powered Gravity Forms.