Organization & Contact Information:

Name of Your Organization:*

Organization Contact:*

Organization Contact's Phone:*      Organization Contact's E-mail:*

Address:*

City:*      State/Province:* Select State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Other Not Applicable      Zip Code:*

Website:*

Will a special tracking link or promotional code be necessary in order for the proceeds of your product(s) to be donated to the National Fallen Firefighters Foundation?* Yes   No

Product Information:

Product Name:*

Briefly Describe Your Product:*


Is your product currently available?* Yes   No, but this product will be available on:

Retail Cost of Your Product:* Percentage or Dollar Amount Per Product Donated:*

The National Fallen Firefighters Foundation name and logo are protected by registered trademark and may not be used on products. However, you may use the Foundation name and logo on your product packaging. Please describe how you will use the name and/or logo on your product packaging and in your marketing materials.

Where will your product will be sold?* Select where will your product will be sold Internet Retail Stores Both on the Internet and in Retail Stores

National Fallen Firefighters Foundation Awareness:

How did you hear about the National Fallen Firefighters Foundation?* (Check all that apply)
Internet (Website, Online Advertisements)
Social Networking (Facebook, Twitter, LinkedIn, etc.)
Search Engine
Printed Material (Advertisements, Brochures, and Other Literature)
News Articles
Fire Service Survivor
Co-Worker
Tradeshow
Event
Television
Radio
Other: