Susan G. Komen® - Survey - Third Party Fundraiser Application

THIRD PARTY INFORMATION

*1.

Question - Required - FULL LEGAL NAME OF THIRD PARTY:

*2.

Question - Required - ADDRESS:

*3.

Question - Required - CITY:

*4.

Question - Required - STATE:

*5.

Question - Required - ZIP:

6.

Question - Not Required - WEBSITE:

3RD PARTY CONTACT INFORMATION

*7.

Question - Required - FIRST NAME:

*8.

Question - Required - LAST NAME

*9.

Question - Required - E-MAIL:

*10.

Question - Required - TELEPHONE

EVENT INFORMATION

*11.

Question - Required - EVENT NAME:

*12.

Question - Required - DATE OF EVENT:

Month

Day

Year

*13.

Question - Required - LOCATION OF EVENT:

BUDGET/DONATION INFORMATION

*14.

Question - Required - DONATION STRUCTURE (Describe basis of donation to be made to Komen Dallas County i.e. pledge, flat donation, event admission, guaranteed minimum):

15.

Question - Not Required - PROJECTED INCOME:

16.

Question - Not Required - PROJECTED EXPENSES:

*17.

Question - Required - PROJECTED DONATION:

For events or sales with a guaranteed donation of $500 or more, the Affiliate will grant the use of our name. For events or sales that guarantee a donation of $2,500 or more, the Affiliate will grant the use of our name and logo.

18.

Question - Not Required - SPECIAL TERMS/ADDITIONAL OBLIGATIONS/OTHER

*19.

Question - Required - PROMOTION OF EVENT (Third Party may only promote the event in the Dallas County Affiliate service area of Dallas County):

All promotional and sales materials advertising the fundraiser must state the exact dollor amount or percentage of retail price of all monies from the fundraiser that will be donated to Komen Dallas County in a clear, unambiguous and readily identifiable fashion.

Komen Information

Komen does not endorse products or services of any kind.
Because of IRS regulations, Komen is unable to assist with promotion or advertising of your company, event or product.
Use of the Komen logo requires a legal contract.
Once your application is reviewed, a Komen representative will contact you for more information.

Disclosure
For the protection of the consumer, the Better Business Bureau requires that the anticipated amount or percentage of the proceeds from sales to benefit a charity be posted at the point of purchase (i.e. $1 or 5 % of each purchase or ticket benefits X charity).

Using the Komen name or logo
Komen’s logo is trademarked, and any use without express written permission is illegal. Use this form to request permission.

OUR PROMISE
The Susan G. Komen promise: to save lives and end breast cancer forever by empowering people, ensuring quality care for all and energizing science to find the cures.