Third-Party Fundraiser Application - The BackStoppers, Inc.

Fundraiser Date *

Fundraiser Title *

Fundraiser Organizer *

Start Time

End Time

Fundraiser Location/Address

Fundraiser Description *

Please describe in detail the proposed fundraiser and all additional features. Please note, unlimited alcohol and an open bar cannot be approved.

How are funds raised for BackStoppers? *

registration, admission, food sales, % of proceeds, etc.

Is BackStoppers the sole beneficiary of this fundraiser? *

If no, please name the other beneficiaries and describe extent:

BackStoppers representative/speaker

Name *

First

Last

Organization/Company:

Street Address:

Phone: *

Email: *

I have read and agree to the terms below.

Applicant has read the Third-Party Fundraiser Guidelines Benefitting The BackStoppers® and agrees to abide by them. Applicant understands that approval must be granted by The BackStoppers® Events Manager before Applicant can plan or promote the proposed fundraiser. BackStoppers® is not liable to any vendor or other third-party for any fees, costs, or payments of any kind associated with the fundraiser.

Name