REGION III EVENT FUNDING REQUEST FORM

 WSO IG #:____________            Intergroup Name:_______________________

 Event Day, Time, Place: ___________________________________________

 Type of Funding: 

“First-Time” Intergroup q S&T q Speaker q WSBC q

Name of Person to be funded: _______________________________________
 

Contact Name___________________________     Phone: ________________
 

E-Mail Address:   _________________________________________________
 

Mailing Address: _________________________________________________
 

City, State, Zip: ________________________    Amount Requested:_________
 

 Submitted By: ________________________________   Date: _____________