DONATION REQUEST FORM

Name of your organization:*

Your Name:*

First NameLast Name

Your position: *

Contact person (if other than you):

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone:*

Please enter a valid phone number.

Email Address:*

example@example.com

Are you a non-profit charitable organization?*

YesNo

Tax ID# (required)*

If this doesn't apply to your event enter NA in the box above.

501(c)(3) (required)*

If this doesn't apply to your event enter NA in the box above.

Name of Event:*

Date of Event*

Date

Nature of event (scholarships, raise awareness, raise funds) *

Is there a ticket/admission fee to this event? If yes, please move to answer the next question)*

YesNo

If you answered yes to the above question, how much are the tickets?

What will the donation be used for?*

RaffleSilent AuctionLive AuctionOther

What organization will receive the proceeds of your event?*

Will Virginia International Raceway be included in any advertising you do for your event? If yes, please list below*

YesNo

Describe types of advertising you plan to include Virginia International Raceway in:

Will you distribute VIR brochures at your event? If yes, please choose the quantity below:*

YesNo

Quantity of brochures you would like to have for your event:

2550100200

If you need a different quantity than the one listed above, please indicate it in the space below.

Donation Agreement:

I agree that the above information is accurate. I understand that this is a request and I will not receive a donation from Virginia International Raceway until the Donations Committee has approved it. I am preparder to answer any quesitons related to the submission and provide necessary paperwork if asked. I will use the donated item/tiemms for the purpose to which it is intended and will not re-sell the items for profit. Failure to comply will negatively impact VIR's consideration of future requests.

Attach a written request on your organization's letterhead 60 days prior to your event. *

Signature*