Win a Free Website

Thank you for your interest in The Wired Mouse and our efforts to impact one of our local organizations. Please fill out the form below to be registered for your chance to win. We request that you be creative with your approach. Applications that stand out (ie: funny, include great ideas, impact on local community, etc) have a great chance to win.

For additional information please consult our terms and conditions documentation. Thank you and good luck!

Contact Information

Organization Name *

Date Established *

Month

Day

Year

Mailing Address *

City *

State *

Zip *

Telephone *

Fax

Current Website URL

Contact Person Name *

Contact Person Telephone *

Contact Person Email *

General Information

How did you hear about this offering? *

Select a category that best describes your organization *

What age group does your organization work with? *

Please give a brief, comprehensive statement of your general aims and how you achieve them *

You need to demonstrate that your organization has clearly defined objectives and responds to a clearly defined need of the community. Please no more than 1,200 characters.

List any sponsorships received in the last 12 months.

What separates your organization from other organizations? What makes it unique? *

What challanges does your organization face? *

Objectives of Your Organization

What is your organization hoping this website will help you to accomplish? (Select all that apply) *

To raise general awareness of your work/business

To raise awareness of your work/business amongst potential beneficiaries

To attract volunteers

To encourage donation of goods/gifts in kind

To encourage participation in events/activities

To raise money for your work/business

Declaration

Does your organization have an equal opportunities statement?

Is your organization a non-profit 501(C)(3)? Certificate number?

How does your organization receive its’ funding?

Supporting Documents

Attach a copy of your organization’s Mission Statement

Attach a copy of your non-profit certificate (if non-profit)

I Agree *

yes

Please confirm that the information contained in this application is correct to the best of your knowledge, that your organization’s Chief Executive Officer or Chair of Trustees has full knowledge of this application, and that you agree to the Win a Free Website Terms and Conditions.

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

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