Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Name (include title) *

First Name

Last Name

Phone *

Phone number of contact person

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Acceptance *

By checking the Acknowledgement box below, you affirm that you will honestly use the grant funds to provide meals to people in need who have the proper voucher issued by the Lazy Bear Fund, Inc. This serves the function of a signature line.

I Acknowledge