Donation Request Form

Thank you for your interest in promoting your organization with Mylan Park. Fill out the form below to submit your donation request. Please allow 2 weeks for review.  Our team will be in touch with either approval or denial depending on availability, need and organization/event status.

Organization Name *

Organization Non-Profit Status *Charities / Foundations [501c3]Tax ExemptGovernment or Public SchoolChurchesCivic, Veteran or Social Welfare Group [501c4 or 501c19]Social or Recreational Club [501c7]Trade or Professional Association [501c6]Other – Please Specify

If Other, please specify here…

Contact Name *

First

Last

Phone *

Email *

Contact Name [2] – OPTIONAL

First

Last

Phone

Email

Contact Name [3] – OPTIONAL

First

Last

Phone

Email

Organization Mailing Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Organization Phone *

Brief Request Description *

Is there an event date or deadline? *NoYes – Please Specify

Please note that requests must be submitted TWO WEEKS prior to need / deadline.

If yes, provide the deadline here…

Is this an annual event or an on-going need? *NoYes – Please Specify

If yes, provide brief details of event / on-going need below…

Submit