Contact: *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you currently a Rotary member?

Yes

No

Please choose the categories from Rotary's giving categories:

Physical Health and Safety

Socialization

Education / Literacy

Food and Nutrition

Mental Health

Community Beautification

Project Location: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Start Date: *

MM

DD

YYYY

End Date *

MM

DD

YYYY

Authorization I certify that I have the authority to request funds from the Westfield Rotary Club on behalf of the above organization. I understand that the Westfield Rotary may, at their discretion, publicize the fact that funds have been contributed to the organization or individual and the purpose of the funding. Any form of media may be used by the Westfield Rotary at their discretion and may include the use of pictures and the name of the applicant or the individuals benefiting from the donation. *

Agree

Disagree