Dine & Donate Fundraiser Request Form Thank you for choosing Black Bear Diner for your next fundraiser.Things to Know The diners listed below participate in this program. If you do not see your preferred diner here, please contact them directly. Events are held on Mondays, Tuesdays, and Wednesdays, from open to close of business with no more than one event per six months per organization. Guests must show or provide the promotional code assigned to your event to apply their check to your fundraiser. We agree to donate 20% of pre-tax sales per guest check associated with your organization's promotional code from your scheduled event time. This includes sales from dine in and online orders placed through BlackBearDiner.com. We will provide a reproduceable promotional flyer with a promotional code and social media graphic approximately three weeks before your event. We will share your event on our local Facebook page the day of your event. Partnership AgreementYou agree to promote your event using the materials we provide through your own newsletters, social media accounts and other available channels. The more you promote, the more you will earn.Please complete and submit this form thirty (30) days before your preferred event date. Question Title * 1. At which diner would you like to hold your event? American Fork UT Baytown TX Boise N (W State Street) ID Brownsville TX Buena Park CA Bullhead City AZ Burleson TX Chandler AZ Chino CA Cottonwood AZ Cypress TX Davis CA Downey CA Draper UT Fayetteville AR Fort Worth - Alliance TX Fullerton CA Gilbert AZ Glendale AZ Goodyear AZ Harker Heights Harlingen TX Henderson NV Houston - Richey Rd TX Humble TX Katy TX Idaho Falls ID Independence MO La Habra CA Lake Havasu AZ Laredo TX Las Vegas - LV Blvd South NV Las Vegas - Sahara NV Las Vegas - Tropicana NV Laveen AZ Layton UT League City TX McAllen TX Mesquite TX Midwest City OK Modesto CA Moore OK Moreno Valley CA Mt. Shasta CA Napa CA North Little Rock AR Ogden UT Olathe KS Orem UT Owasso OK Pasadena TX Quail Springs OK Redding CA San Antonio - Military Drive San Antonio - Monterrey Village Santa Ana CA Scottsdale, AZ Signal Hill CA Sonoma CA St. Charles MO Sugar Land TX Tempe AZ The Woodlands TX Torrance CA Tucson AZ Tulsa OK Twin Falls ID Waco TX Walnut Creek CA West Valley City UT Woods Cross UT Yuma AZ Question Title * 2. Have we partnered with you for a previous Dine & Donate night? Yes No Question Title * 3. If yes, was your last event over six months ago? Question Title * 4. When would you like to hold your event? Please give us three options that could work for you. Day Month Date 1. Monday Tuesday Wednesday 1. Day menu January February March April May June July August September October November December 1. Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1. Date menu 2. Monday Tuesday Wednesday 2. Day menu January February March April May June July August September October November December 2. Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2. Date menu 3. Monday Tuesday Wednesday 3. Day menu January February March April May June July August September October November December 3. Month menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 3. Date menu We schedule fundraising events for one full day per organization on Mondays, Tuesdays, and Wednesdays, from open to close of business with no more than one event per six months per organization. Note: Selecting these dates does not guarantee the date. We will contact you when we secure the date with the diner. Question Title * 5. How would you like the name of your group to appear on the promotional flyers? Question Title * 6. Does your organization have a Facebook Page? If so, what is the Page Name? (We will use this to post and tag your event from our Page.) Question Title * 7. Please tell us about you and your organization. Event contact name (person) * Organization name (to whom the check will be made payable) * Street Address (where check will be mailed) * Address 2 City/Town * State/Province * ZIP/Postal Code * Organization website address Contact Email Address * Contact Phone Number * Question Title * 8. Is your organization set up as a tax-exempt 501(c)3? Yes No Not sure If yes, please provide your TAX ID# Question Title * 9. Briefly describe why your organization is trying to raise money. Include who or what it will support. Question Title * 10. How many guests might we expect from your group? Please estimate. Thank you. We will be in touch with you by email within two weeks. If you have questions, please contact our Outreach Marketing department or call 530.243.2327. While you wait, be sure to join our eClub for a FREE meal when you join and another on our birthday!Be sure to click the DONE button below to submit this form. Question Title * 11. Did a team member refer you to this fundraising program? If so, we'd like to recognize them. Please provide their name. Done