GlimpseBack.com • Gift Acceptor Information

All gray fields are required.

Organization Information

* By selecting this box, I agree to all of these terms and conditions of GlimpseBack.com.

Are you applying as a Chapter
or as the National/Headquarters?*:

National / Headquarters

Chapter

Legal Name Of Non-Profit
Organization (National/Headquarters)*:

Abbreviation of Non-Profit (if any):

Address*:

City / State / Zip / Country*:

Contact Name and Title*:

Contact Email Address*:

Contact Phone Number/Extension*:

Official Web Address*:

If you are applying as a local chapter, please answer all the following questions:

Local Chapter Address:

City / State / Zip / Country:

Contact Name and Title:

Contact Email Address:

Contact Phone Number/Extension:

Official Web Address:

Personal Information

The following questions pertain to the person filling out this application:

Your Name and Title*:

Your Department*:

Your Email*:

Your Password (for updating info)*:

Confirm Password*:

Your Work Telephone/Extension*:

Your Work Fax*:

Other Contact Info:

Organization Questions

The following questions pertain to the Non-Profit in which you represent:

Does your Non-Profit accept Donations through credit card processing?*:

Yes

What is the URL address that goes directly to the form/page on your Non-Profit site,

What is the mailing address (for those who prefer to send a check or money order)*:

"Pay To The Order Of"*:

What is the "for more information" email address, you would like us to list on our site?*:

What is the telephone number, for those who prefer to call and ask questions?*:

What is the minimum donation that your organization will accept?*:

Is this Non-Profit Organization a 501(c)(3)?*:

Yes

Please allow up to 48 hours for the approval process.
If we have any questions we will contact you by phone.