Contribution Requests Form

Atmos Energy asks that all organizations requesting financial support from us complete this questionnaire. We ask that your request be submitted at least three weeks in advance of your event. Those not providing ample time for consideration may limit their opportunity for support. Completion of this form does not guarantee that Atmos Energy will be able to fulfill the request. (Please complete form and submit when complete.)

Organization Name*:
Contact Name*:
Phone Number*:
Email Address*:
Mailing Address*:
Is this a P.O. Box?	Yes  No
Physical Address*:
City*:
State*:	Colorado Kansas Kentucky Louisiana Mississippi Tennessee Texas Virginia
Zip*:
Is this organization a 501-(c3)?:	Yes No
Does your organization depend on funds from other social service agencies such as United Way?:	Yes No
Are these funds being requested in support of an event? Please provide the event name and date?:
What is the organization's primary mission?:
Amount requested*:
Date funds needed by*:	select date
Will there be any advertisement or promotions featuring Atmos Energy? If so, please describe: (Maximum characters: 650) You have characters left
Has Atmos Energy participated in the past? In what way?: (Maximum characters: 650) You have characters left