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Walk To End HIV -
Benefiting Agencies Form
Benefiting Agency Name:
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501(c)3 Organization Name (if different):
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Agency Street Address:
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City:
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State:
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Zip Code:
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Contact Full Name:
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Contact Email:
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Contact Cell Phone:
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Agency Website:
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Agency Social Media Platforms (list all):
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Non-Profit 501(c)3 Determination Letter:
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Organization Completed W-9 Form:
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Benefiting Agency Logo:
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Benefitting Agency ALL-WHITE logo:
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Acknowledgment: By checking this box you acknowledge that you have read, understand, and agree to the terms and conditions contained above. As well as that the information on this application is true and correct to the best of your knowledge and you are authorized to enter into this agreement on behalf of your organization.
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Walk To End HIV - Benefiting Agencies Form