US Assistance Request

First Name:	*
Last Name :	*
Organization Name:	*
Organization URL
Is your organization an IRS 501(c)3 not-for-profit?
	*	Yes No
If no, please elaborate on status:
Street Address:	*
City:	*	State*- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code:	*	United States
Email address:	*
Phone :		Fax :
Project Name:
Please explain how your organizations goals are in line with the mission of Going To Bat. Also include how many children will benefit.
Description of Need:
Security Code	*