Assistance Request

Name of requesting entity:

Mailing address:

Street:

City:

State:

Zip:

Telephone number:

Website (if any):

Employer Identification Number (EIN):

Note: This number will be used to verify applicant’s status as a qualified 501(c)(3) organization.

Brief description of entity’s charitable activities:

Brief description of the specific project for which you are requesting funding or volunteer assistance:

Dollar amount of financial assistance you are requesting ($):

Number of volunteers you are requesting:

Total number of volunteer hours you are requesting:

Number of workdays you are requesting:

Number of beneficiaries:

Description of project beneficiaries:

Coldwell Banker or company contact: