Organization Contact Information

Organization Name:

Contact Person First Name: Contact Person Last Name:

Contact Person Phone Number - Area Code: Phone:

Contact Person E-mail:

Complete Name & Address funds raised check should be mailed to:

Name of Clover's Representative:

Choose the date and location of your fundraiser

Note: You may choose any fundraiser date & any fundraiser location.

Select Date of Fundraiser (check one): September 17, 18, 19, 2010 September 24, 25, 26, 2010 October 1, 2, 3, 2010 October 8, 9, 10, 2010 October 15, 16, 17, 2010 October 22, 23, 24, 2010 Other - please contact me for a special request

Select Location of Fundraiser (check one): Berwyn Elmhurst Mount Prospect Naperville (on Chicago Avenue - at Butera Market) Skokie (October only) Westmont Willowbrook Other - please contact me for a special request

NOTE:

With each or your group’s purchases (we sell gift certificates, too), during the above designated dates, your organization will receive 10% of your pre-tax totals, sent to the name and address you listed above 2 weeks after the fundraising event has been held.

This is not a 10% discount for your supporter’s purchases – but it is the percent of the sale we will give to your organization.

Example: Gracie Gardener purchase = $210.58 ($194.78 before taxes), your organization earns $19.48 for that sale.

Visit and shop as many times as you would like – making sure your supporters present a copy of the fundraising flyer each time to record their purchase(customized for your organization).

We request your cooperation in respecting our customers, by not soliciting them in the general vicinity of the location of the fundraiser site listed above.

By pressing the submit button below, I certify that my answers are true and complete to the best of my knowledge. I authorize investigation of all statements contained herein.