La Provence Donation Request Form

We appreciate the opportunity to assist in supporting the needs in our community. We are proud to donate in the form of "Promotion Cards" that can be used towards your dining experience.
You may also use your "Promotion Cards" in our Take-Away/Deli.

 

Organization Name:
Contact Name:
Contact Phone:
Contact Email:
Federal Tax ID:
Address:
City:
State:
Zip:
Event Information
Benefit:
Event Name:
Event Location:
Event Date:
Web Site:
Advertising Deadline:
Donation Deadline:
Donation Type:
(select all that apply)		 Raffle Prize  Live Auction Prize  Silent Auction Prize

Goody Bag  /  Number of Bags: 

Food Donation  /  Number of People: 

Wine Donation  /  Number of People: 

Monetary Donation  Sponsorship

Other: 
Recognition:
(select all that apply)		 Event  Invitation  Program or Newsletter  Web  Signage

Media:   Other: