Legal Name of Organization or Individual Applying for Funds *

Contact Person for Application *

* Please list best person to contact if application is accepted and for media photos and interviews

Phone *

Email *

Mailing Address *

City *

State *

Zip Code *

Zip Code

Amount Requesting *

Detailed Description of Intended Use of Gaming Funds *

Supporting Documents (Optional)

Signature *

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

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