Donation Request Donation Request Form Requesting Entity Name* 501(c)(3) or 501(c)(4) 501(c)(3) 501(c)(4) Is the applicant a non-profit organization (IRS 501(c)(3) or (c)(4))?Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Number of Applicant's Members in CBCA*Please enter a number greater than or equal to 0.How many of the applicant’s members are members of the CBCA?Amount Requested*Purpose of RequestAdditional Efforts in Pursuit of RequestWhat additional efforts, apart from any potential donation from the CBCA, has the applicant pursued to secure donations for the same purpose?Volunteer History for CBCA EventsHas the applicant provided volunteers for any of CBCA’s fundraising events? If so, for how long? If not, has the applicant committed to providing volunteers?Sources of Revenue and ExpenseDoes Applicant Pay Wages, Salaries or Stipends to Staff?* True False Does the applicant pay wages, salaries, or stipends to any of its management or staff?Award Stipulation* Agree By selecting “Agree” the applicant agrees to stipulate that any award will not be used to fund wages, salaries, stipends, or any such expenses to its management or staff.Agreement to Provide Additional Information as 501(c)(3)* Agree By selecting “Agree” the applicant agrees to provide the CBCA, if requested, a copy of its most recent income statement and balance sheet.Post Donation Documentation Agreement* Agree By selecting “Agree” the applicant agrees to provide the CBCA with post donation documentation verifying that CBCA’s donation was used for the purpose for which it was granted.In-Person Presentation on Request* Agree Disagree Will the applicant, if requested, be willing to make an in-person presentation to the executive board and/or membership?Reason for Disagreeing to Presentation On RequestPlease provide a description of why you, as an applicant, would not be willing to, upon request, make an in-person presentation to the executive board and/or membership.Applicant Name* First Last Date* MM slash DD slash YYYY Signature*Please note: if your donation form was properly accepted, you will receive a confirmation email, letting you know that it was received. Thank you.