Worthington Industries'
Corporate Giving Request

Name of Your Organization*
Name of Person Submitting Application*
Title*
First Name*
MI
Last Name*
Organization Title*
E-mail
Name of Executive Director / Senior Officer (if other than person submitting application)
Title
First Name
MI
Last Name
Organization Title
E-mail
Street Address of Organization*
City*
State*
Zip Code*
Phone*
(
)
Facsimile
(
)
Do you maintain an Internet site?*
If yes, what is its URL?
What is the mission statement of your organization?*
What is the main area of focus for your organization?*
 Health and Human Services
 Community Development
 Education
 Arts and Culture
 Environmental Concerns
What is your organization's Tax Identification Number (TIN)?*
Is your organization designated as tax-exempt by the Internal Revenue Service under section 501(C)(3) or section 170(B)(1)(a)(ii)?*
 Section 501(C)(3) - nonprofit
 Section 170(B)(1)(a)(ii) - K-12 school
 No
Is your organization an United Way agency?*
Does your organization prepare an audited financial statement?*
If yes, what is the name of the independent auditor?
Does your organization maintain a Board of Directors?*
If yes, please list the members of your Board of Directors, any Board office held, and their corporate affiliation (if any).
List Board Officers, Worthington Industries employees, and employees from major employers first and in this order of priority.
Board Member
Board Position
Company
Should your organization have more than 12 Board Members, you will have the opportunity to provide a comprehensive list when your request is determined to fall within our contribution guidelines.
.
Is this a corporate request or a request for a specific Worthington location?
Please specify location:*
.
What is the purpose of this request?*
 Annual Campaign
 Project Support
 Capital Campaign
 Debt Retirement
 Event Tickets / Tables
 Membership Dues
 Conference Registration
Please describe the nature of the request and / or program for which you are seeking support. (Please limit your response to 500 words or less.)*
Please define the scope of the project, the size of the constituency served, any goals to be achieved, and how you define success for meeting these goals. (Please limit your response to 500 words or less.)*
What is the amount of the entire project budget?*
$ .00
Please indicate other donors supporting this particular project and the amount they are contributing. (Only list the five largest contributions in case there are many donors.)
Donor
Amount
$ .00
$ .00
$ .00
$ .00
$ .00
What type of support are you seeking?*
Leadership
Donation of Steel Products
Volunteers
Financial
If financial, indicate the amount requested.
$ .00
Of this amount how much is considered a charitable donation?
$ .00
How much is allocated for benefits received? (i.e. - ticket purchases, event registration, advertising, etc.)
$ .00
Is the amount above to be disbursed in one lump sum, or over time in periodic installments?
If the funds are to be disbursed over time, indicate the projected number of payments and their timing.
Fields marked with an -*- are mandatory and require a response.

For assistance, please send an e-mail to our Help Desk