Information about your organization

Organization Name:
Address:
City:		State:	AL AK AZ AR CA CO CT 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 PR RI SC SD TN TX UT VT VA VI WA WV WI WY	Zip:
Phone:		Fax:
Name of Contact Person Familiar with the details of this request:
Title:
Phone:		Email:
Program Category:	Education    Environment    Community Vitality
Date of Incorporation:		Number of Employees:
Number of Volunteers:

Parent Group Information

Name of "parent group":
Address of "parent group":
City:    State: AL AK AZ AR CA CO CT 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 PR RI SC SD TN TX UT VT VA VI WA WV WI WY    Zip:
Population Served by your organization:
Organization's mission:
Organization's history:
Geographical area your organization serves:

Information about your proposal

Requested amount:
Describe the project/program for which support is requested, including projected outcome results.
Goals of the project/program:
How does this project/program benefit the community you serve?:
How and when will this project/program be evaluated?
Are Tesoro employees involved in your organization?
Yes   No
If yes, describe briefly.
Is this a request for renenwed support?
Yes    No
If yes, please attach a final report or evaluation to this application

Budget Information

Annual Operating Budget:
Total Program/Project Budget:
Requested Amount:
List additional sources of support that will be available to cover the balance of the program/operating budget.
Is your organization carrying a deficit?
Yes   No
Attachments
Please include the following with this application:
Is this a request for renenwed support?
IRS 501(c)(3) Determination letter List of Key Staff List of Principal Sources of Income Board of Directors and Officers
Each application is reviewed by a local committee in the area where the charitable organization is located. To find the local address for mailing your charitable contribution application, visit the Social Responsibility section of the Tesoro Web site at www.tsocorp.com