Agency Participation Request |

1. Please complete the entire application. All required fields need to be filled in prior to submission.

2. Please ensure that your Agency Director approves participation in this program. By placing his/her name on the form confirms that they agree with participation in the program.

3. Include a copy of your IRS/US Dept of Treasury Letter of Determination that states your 501c3 status or letter of good standing. You can email, fax or mail this to us.

If you have questions concerning completing the form or would like to speak with someone regarding your request, please send and email bras@brarecycling.com or call 480-988-2283.

Agency/Organization Name:
 * required

Primary Contact Person:

First Name:
 * required
Last Name:
 * required
Phone:
 * required
Email:
 * required
Mailing Address:
 * required
City:
 * required
State/Province:
 * required
Zip:
 * required
Country:
 * required

Secondary Contact Person:
(If there is not a secondary contact please leave blank)

First Name:
Last Name:
Phone:
Email:
Mailing Address:
City:
State/Province:
Zip:
Country:

Agency Mission:
How will receiving recycled bras further your mission?
On average how many clients a month does your agency serve?
 Please provide an estimate of the quantity and range of sizes that you might need. This gives us an idea of the sizes and quantity to plan for.
What percentage of the population you serve is low income? (Low income=below 200 percent of the federal poverty level; currently $37,700 per year for a family of 4)

May we put a link to your agency on our website?

If yes, please provide the web address and email your logo to info@brarecycling.com

Would you be willing to have a link from your website to The Bra Recyclers Site?
 * required
 * required
The Bra Recyclers is excited about supplying recycled bras to women in communities around the world.