OFFICE: 570-278-1129 CONTACT_US@PUMPNPANTRY.COM SPONSORSHIPS For nearly 40 years Pump N Pantry has made a commitment to invest in the communities where we have our stores, and where our customers and employees live. Pump N Pantry earnestly considers each donation request when made by a local non-profit organization. However, due to the volume of requests received each year, Pump N Pantry is unable to donate or respond to every request. Please note the following are ineligible for contributions: Events that do not benefit a charity Individuals Individual Competitions, such as beauty pageants Race teams and car clubs Companies receiving a percentage of the money raised Political entities IF YOUR CHARITY WOULD LIKE TO MAKE A QUALIFIED DONATION REQUEST PLEASE COMPLETE THE QUESTIONNAIRE BELOW AT LEAST 30 DAYS BEFORE THE REQUESTED DONATION DATE. SPONSORSHIP REQUEST FORM Name of your Non-Profit Charity or Charitable Benefit* Organization Tax ID (501c3)* Purpose of charity or benefit* Donation date requested* Date Format: MM slash DD slash YYYY WHERE SHOULD THE DONATION BE SENT? First name* Last name* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Islands Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini (Swaziland) Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu US Minor Outlying Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands Country Email* Phone* What is the donation being requested?* How will the donation be used by the charity? Please be specific.* Is there advertising involved?* Yes No PUMP N PANTRY Main Office 754 Grow Avenue Montrose, PA 18801 Phone: 570-278-1129 ALL THE GOOD All the Good Things to Eat ORDER ONLINE All the Good Things to Drink All the Perks N Rewards All the Good Jobs ALL ABOUT US About Us Store Locator Community Sponsorships Contact Us © 2017 Pump N Pantry Convenience Stores, Inc. via FreshySites - Website Design