EmailMe Form - North Carolina 811 Center Funds Request Form

Name of Utility Coordinating Committee

Date of Request

MM / DD / YYYY

Committee Chairperson

Chairperson's Phone Number

### - ### - ####

Event Type:

Damage Prevention Awareness Breakfast

Damage Prevention Awareness Luncheon

Damage Prevention Awareness Dinner

Safety Tailgate Meeting

Other, Please Specify

Details of event type if you chose other

Event Sponsors

Event Date & Time

MM / DD / YYYY HH : MM AM/PM

Event Location

Street Address City State / Province / Region Postal / Zip Code Country / Region

Number of Guests

Cost Per Person

Requested Fund Amount ($200 or less)

Check Payable To

First Last

Mail Check To

Street Address City State / Province / Region Postal / Zip Code Country / Region

Person Requesting Funds

First Last

Phone Number

### - ### - ####

Email Address