Mad Ants' Donation Request Form
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DONATION REQUEST FORM
Thank you for your interest in obtaining a donation from the Fort Wayne Mad Ants. Please note that
completion of this form is a request only and does not guarantee a donation. All request forms must
be received in the Mad Ants’ office at least 4 weeks prior to the event.
Name of Organization: ____________________________________ Phone: _______________________
Mailing Address: ______________________ City: ___________________ State: ______ Zip:__________
Organization Tax-ID Number: ____________________________________________________________
Description of organization or mission statement: ___________________________________________
_____________________________________________________________________________________
Event Name: ___________________________________________________ Event Date: ____________
Event Location: _________________________________________________ Event Time: ____________
Event Contact Person: ______________________ Contact Email: _______________________________
Contact Phone: ___________________________ Estimated Attendance: _________________________
Event Description: _____________________________________________________________________
_____________________________________________________________________________________
Description of Request (for tickets: minimum/maximum number of seats; preference of weekend or
weekday; ADA needs): __________________________________________________________________
_____________________________________________________________________________________
How will this donation be used (auction, raffle, etc.): _________________________________________
_____________________________________________________________________________________
How will this event will be promoted: _____________________________________________________
Confirmation of donation needed by (date): __________________________Today’s Date: __________
The Fort Wayne Mad Ants receive myriad requests for donations throughout the year, and I
understand that they reserve the right to refuse any request at their own discretion. Submission of this
form does not guarantee that I will receive a donation. If the Mad Ants donate an item to me or my
organization, I will use it strictly for charitable purposes through auctions, raffles, etc. I am aware of
the Mad Ants policy that permits just one (1) donation per calendar year per organization.
Printed Name: _____________________________ Title: ______________________________________
Signature: ____________________________________________________________________________
One Colony, One Community
1910 St. Joe Center Road, Suite 61
Fort Wayne, IN 46825
Phone: 260-469-HOOP
Fax: 260-469-4674
Contact: Audrey Siebrase at
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