Date: 

Name Of Organization: 

Phone Number:  Social Security / Tax I.D.:

Mailing Address:   City: State: Zip:

E-Mail Address:

Purpose for the donation: (i.e. participation, sponsorship, ad, auction items, etc.)

Amount Requested:

Auction Item Requested: (i.e. hotel stay, dinner, spa gift certificate)

Has Tachi Palace provided a donation in the past?

Yes No

If yes, when:    Type of item:

Additional Information or Comments:

The above infomation is correct to the best of my knowledge.

Date        Signature of Applicant