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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe 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* Event Start Time* : HH MM AM PM Date event will end* (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 Jordan Curry, Program Coordinator, at 412-281- 3466 or firstname.lastname@example.org 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* 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 Jordan Curry, Program Coordinator, 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.