Mississippi State Athletic Autographed Item Requests Page 2

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Mississippi   S tate   U niversity   A thletics   A utographed   I tem   R equest   F orm    
 
Organization   I nformation  
Organization   N ame:   _____________________________________________________________________________________    
Contact   N ame:     _ _________________________________________________________________________________________    
Address:       _ _______________________________________________________________________________________________    
City:       _ ________________________________________       S tate:       _ __________________       Z ip:   _ _______________________    
Phone:       ________________________________________________   E mail:       _ ________________________________________        
Date   o f   E vent:  _________________________________________    
 
Organization   C lassification   ( check   a pplicable   b ox):  
q Elementary/Middle/Junior   H igh   S chool   ( Grades   K -­‐8)  
q         H igh   S chool   ( Grades   9 -­‐12)/Preparatory   S chool/Junior   C ollege  
q         N on-­‐Profit/Charitable   O rganization  
q Other   ( please   d escribe):  ___________________________________________________________________________    
 
Will   t he   i tem   b e   s old   o r   a uctioned   o r   f undraising   p urposes?                 q     Y es                     q     N o  
If   s o,   w ill   g rades   9   –   1 2,   p rep   s chool   o r   j unior   c ollege   s tudents   b enefit   f rom   t he   s ale?      
q     Y es                     q     N o  
 
If   i tem   i s   t o   b e   s old   o r   r affled   i n   a   f undraising   e vent,   a   f lyer,   i nvitation   o r   m emo   d escribing   t he   e vent  
must   b e   i ncluded   w ith   t his   f orm.  
 
By   m y   s ignature   b elow,   I   c ertify   t hat   t he   i tem   p rovided   t o   m e   p er   t his   r equest   w ill   b e   u sed   o nly   i n   t he  
manner   I   s pecify   a bove.     I   u nderstand   t hat   t his   i tem   m ay   n ot   b e   s old   f or   p ersonal   p rofit   n or   d onated  
to   a   f undraising   a ctivity   u nless   d esignated   a s   s uch   a bove.     I f   I   a m   g iving   t his   i tem   a s   a   g ift,   I   c ertify  
that   I   w ill   n otify   t he   r ecipient   o f   t he   a pplicable   r egulations.     L astly,   I   u nderstand   t hat   t his   i tem   m ay  
not,   u nder   a ny   c ircumstance,   b e   r esold   o r   a uctioned   t hrough   t he   i nternet.      
 
Please   p rint   y our   n ame:   _ _______________________________________________________________________________    
 
Signature:  _____________________________________________________________________________   Date:____________  
 
 
For   O ffice   U se   O nly  
Compliance   A pproval:     q
Granted                     q
Denied                                   S taff   M ember   I nitials:     ________________________________    
   
Request   f orwarded   t o:       ______________________________________                                     D ate:     _ ________________________________________________  
 

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