Benefit Fundraising Form - Zippy's Restaurants

Organization Information

Name of Organization*

Number of Members*

Where is your organization located in?*

Hawaii
Nevada

If your Organization is from Hawaii, are you eligible for a GE Tax Exempt rate (.5%)?*

Yes
No

Number of Tickets

How many tickets would you like?*

There is a minimum of 200 tickets, and can be increased in increments of 50.

Applicant Information

Please provide 2 applicants who Zippy's may contact regarding your inquiry. Applicants must be over 18 years of age, living in different households and have full-time employment.

A. Primary Applicant

Primary Applicant Name*

First Name Last Name

Mailing Address*

Address City State ZIP Code

Primary Phone*

Alternative Phone

Business Phone

Email Address*

Employer*

B. Secondary Applicant

Secondary Applicant Name*

First Name Last Name

Mailing Address*

Address City State ZIP Code

Primary Phone*

Alternative Phone

Business Phone

Email Address*

Employer*

Invoices will be emailed to the primary and secondary applicants listed above. If the email is different, include email here:

Other

How did you hear about our fundraising program?

Other*

Area where tickets will be sold? (Check one)*

Purpose of Fundraising*

CAPTCHA

Badura

Dillingham

Ewa

Hilo

Kahala

Kahului

Kailua

Kaimuki

Kalihi

Kaneohe

Kapahulu

Kapolei

Koko Marina

Makiki

McCully

Mililani

Nimitz

Pearl City

Vineyard

Wahiawa

Waiau

Waipahu

Waipio