On Behalf of a Grateful Nation: Contribution Form

Contribution Form

	Name:
	Address:
	Phone Number :
	Email Address:
	Business Name(if applicable):

	1. Are you a business owner/representative, or an individual?
	business owner/representative individual

	2. What would you like to contribute?
	an item of value a discounted or complimentary product or service
	3. How would you categorize your gift? (Please select one)


	4. Would you like this gift to be perpetual, for a limited time, or one time only?
	perpetual limited time one time only
	If limited time, please specify expiration date :

	5. Would you like this gift to be available to all that are eligible, or to one/few recipients?
	all eligible recipients an individual/small group of eligible

	6. Do you have a preference to whom you would like your gift to be applied?
	an injured veteran the family of a fallen soldier no preference

	7. Please describe in detail your contribution ....


	8. What is the estimated fair market value of your contribution?

By submitting this form, you are stating that the information you have provided is true and accurate to the best of your knowledge. The information that you provide regarding yourself/the nominee is protected by our Privacy Policy and will not be shared with third parties unless required by law. Thorough vetting of the eligible recipient will be completed prior to any good, service, product or item being awarded. We will contact you when a match is made, and with their permission, provide you with the recipient’s basic information.