Non-profit Application

Operation Round-Up Enrollment Form for Donation Organization and/or Agency

Name of Organization*

Address (Street or P.O. Box)*

City*

State*

Zip Code*

County*

Contact Person Name*

Contact Person Title*

Contact Phone Number*

Contact Email Address*

Is the organization requesting funding, exempt from payment of income tax? *

Yes No

If yes, please attach a copy of an IRS letter indicating your organization's 501(c)3 status.* (pdf, doc, docx, jpg, jpeg, png, gif)

A copy of the financial statement(s) for the most previous year should be provided. (pdf, doc, docx, jpg, jpeg, png, gif)

Have you previously received funding from Operation Round-Up? *

Yes No

If yes, please list the date and amount you received.*

Describe the purpose for the funds requested. Please include the amount requested and specifics of how the funds will be used. *

List other sources of funding being used in the request described above.

Is your organization served electric power by First Electric Cooperative? *

Yes No

If so, do you authorize permission to enroll your organization’s account(s) in Operation Round-Up, if awarded funds? *

Yes No

The information contained in this statement is for the purpose of obtaining funding from the First Electric Trust on behalf of the undersigned. The undersigned understands that the information provided herein is used in deciding to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the First Electric Trust may consider this statement as continuing to be true and correct until a written notice of change is provided. The First Electric Trust is authorized to make all inquiries they deem necessary to verify the accuracy of the statements made herein.

Name of Organization*

Representative's Signature (type your name as you would sign it)*

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Celebrating Co-op Month at First Electric

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Easily pay
your bill

Your Account at
Your Fingertips

Quickly Report
an Outage

Monitor your
Energy Usage

Easily pay
your bill

Celebrating Co-op Month at First Electric

Monitor your Energy Usage

Community

Non-profit Application

Operation Round-Up Enrollment Form for Donation Organization and/or Agency