Community Matters Application

To submit a formal request to Integra for your charity or organization, please complete the following online application and your request will be reviewed by the Community Matters Committee. Required fields are marked with an asterisk.

Organization Information

Integra Market Area:	Select Your AreaArizonaCalifornia - SacramentoCalifornia - Santa RosaColoradoEastern WashingtonIdahoMinnesota - OutstateMontanaNevada - Las VegasNevada - RenoNorth DakotaOregon & SW WashingtonPrior Lake Area, MinnesotaTwin Cities, MinnesotaUtahWestern Washington
Name of organization*:
Federal tax ID number:
Contact name*:
Contact title*:
Contact phone number*:
Fax number:
Contact e-mail address*:
Web address:
Address line 1*:
Address line 2:
City*:
State*:	- Select - Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
Zip Code*:
Focus of organization: Check all that apply.	Youth Health & Wellness Community Development Other
List any Integra Telecom employees involved in the organization and their role:
Provide a brief overview of the organization and its mission:
Provide a brief description of your request. Please include any specific requested donation amounts, event dates, promotional items, etc:
Integra occasionally has surplus computer equipment that we make available to qualified non-profit organizations. Would you like to be considered for an equipment donation?	Yes No

Requestor Information

Your name:
Your Phone Number:
Your E-mail Address:
Additional comments: