Restaurant Charity Request Form for Full Moon Madness

Today's Date

Organization

Contact Person - First Name   Last Name

Title

Contact Email

Organization  Address

City   State - Select - Connecticut Maine Massachusetts New Hampshire Rhode Island Vermont  Zip

Phone    Fax

Tax ID #

Margaritas Restaurant Location - Select - Connecticut - East Hartford Connecticut - Mystic Maine - Auburn Maine - Orono Maine - Portland Brown Street Maine - Augusta Maine - Portland St John Street Massachusetts - Revere Massachusetts - Waltham Massachusetts - Weymouth New Hampshire - Dover New Hampshire - Exeter New Hampshire - Lebanon New Hampshire - Portsmouth New Hampshire - Salem New Hampshire - Manchester New Hampshire - Nashua New Hampshire - Keene New Hampshire - Concord

Have you spoken with a Margaritas manager about your organization yet?  No    Yes    Manager's name

Preferred time of year you would like to work with Full Moon Madness

1st Choice - Select - Q1 (Jan, Feb, Mar) Q2 (April, May, June) Q3 (July, Aug, Sept) Q4 (Oct, Nov, Dec) No Preference Comments 2nd Choice - Select - Q1 (Jan, Feb, Mar) Q2 (April, May, June) Q3 (July, Aug, Sept) Q4 (Oct, Nov, Dec) No Preference

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