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* 1. Name of Organization:

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* 2. Name of Representative:

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* 3. Title of Representative:

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* 4. EIN Number (or charity registration number):

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* 5. Address Information

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* 6. Please list your organization's mission statement.

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* 7. Describe the proposed project/program for which you are requesting support and explain how this project or program benefits the community.

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* 8. What is the timeline for implementation of the program or project?

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* 9. If the program or project is already under way, what has been accomplished so far?

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* 10. Please request a specific dollar amount from Halliburton to support this program or project.
(all funds must be requested in USD)

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* 11. If the program or project is ongoing, how will it be sustained after Halliburton's funding ends?

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* 12. How will you measure the impact of the funds granted by Halliburton?

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* 13. Please list any employee volunteer opportunities associated with this request.

Verification Agreement:

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* 14. I certify that I am authorized to represent this organization and that the information contained in this application is accurate.

Please submit a copy of the Internal Revenue Service letter verifying your organization's 501(c)(3) tax-exempt status or other documentation confirming your organization is a registered charity, your most recent audited financial statement or IRS Form 990, and a list of major corporate and foundation donors for the past two years.

Please send to the above files to Community Relations, along with the name of your organization.
Once your charitable contribution request has been submitted, it will be reviewed after the close of the quarter. You will be notified in writing of the decision. Thank you.
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