Community Matters Application

To submit a formal request to Integra for your charity or organization, please complete the following online application and your request will be reviewed by the Community Matters Committee.

Required fields are marked with an asterisk.

Organization Information

Integra Market Area:
*Name of organization:**
*Federal tax ID number:**
*Contact name:**
*Contact title:**
*Contact phone number:**
Fax number:
*Contact e-mail address:**
Web address:
*Address line 1:**
Address line 2:
*City:**
*State:**
*Zip Code:**

Focus of organization: Check all that apply.	Youth Health & Wellness Community Development Other

Are there any Integra Telecom employees involved in the organization?	Yes No Unknown
If yes, please provide the name of the Integra employee:

Provide a brief overview of the organization and its mission:
Provide a brief description of your request. Please include any specific requested donation amounts, event dates, promotional items, etc:

Requestor Information

Your name:
Your Phone Number:
*Your E-mail Address:**
Additional comments: