Donation Request Form

**Please note: This is not a contract**

Backroads must receive this completed form at least 60 days prior to the event.

Please print and return to Liz Hale via fax at 415-464-9511. Once your application is received, you will be contacted by Backroads regarding the status of your request.

Name of organization ________________________________________________

Name of event ________________________________________________

Type of event (please check one)
______ Live ______ Silent ______ Online

Date of event _________________________

Projected attendance ___________________

Fund-raising goal $_____________________

Location of event (please include city and state) ____________________

Name of primary contact ________________________________________________

Primary contact mailing address ____________________________________

Phone ___________________________________________


E-mail ___________________________________________

Fax ________________________________________________

How will Backroads be promoted before and during your event?

________________________________________________

________________________________________________

Deadline to include logo in event invitation

________________________________________________

Deadline for promotional trip copy and images

_______________________________________________

E-mail address and contact information of printer/designer

________________________________________________

Format for logo (please check) ______ JPEG ______ EPS ______ PDF

Please specify one trip requested for donation

________________________________________________

Trip name as it appears in catalog or on the Web

________________________________________________

Catalog Name _____________________________________

Catalog Page # _______

Activity (please check) ______ Biking ______ Walking/Hiking _____ Multisport

Accommodation (please check) ______ Premiere Inns ______ Casual Inns ______ Camping

Total retail trip cost of one (must include internal airfare, if applicable), as it appears in catalog/Web $_______________________________________________

Retail value for trip for two (previous answer x 2) $__________________

Minimum bid required (previous answer x 75%) $________________________

Other auction items at your event

________________________________________________

I understand that Backroads will donate one trip and the organization will purchase one trip ______ Yes ______ No

I understand that the minimum bid requirement is no less than 75% of the total retail cost of the trip for two ______ Yes ______ No

I understand that auction committee members and those associated with the organization are not eligible to win the Backroads trip __ Yes __ No

I have read and understand the program policies ______ Yes ______ No

Signature
________________________________________________

Print name
________________________________________________

If you have any questions, please contact Liz Hale by phone at 510-527-1555 ext. 119 or e-mail at lizh@backroads.com.