Outreach – Request for Assistance | Assistance League

Agency Name(Required)

Contact Name

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone Number

Cell Phone Number

Fax Phone

Email(Required)

Is your agency a 501c3?(Required)

Yes

What is your source of funding?(Required)

What would you like to share with us about your agency?(Required)

Please provide your mission statement(Required)

Describe your need or request. Please be as specific as possible. List any questions below and someone will contact you.(Required)

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Number of individuals this request would serve(Required)

Projected cost of this request(Required)

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