PROMOTIONAL ITEM REQUEST FORM
PROMOTIONAL ITEM REQUEST FORM Name: Organization (If Applicable): Address: ___________________________________ City, State, Zip: Phone 1: Phone 2: Email: Your organization is:
Return to: Compliance Office 510 West 49th Street Indianapolis, IN 46208 [email protected]
Fax:
Educational Agency (other than grades 9-12 or junior college) Non-Profit/Charitable Agency** Butler Organization State name: NCAA School/Conference Other
**Documentation of non-profit status must accompany this form.
Name of Activity: Date of Activity: City and Site of Activity: Describe below the type of Promotional/Fundraising Activity (Attach copy of flyer, if available)
Name the beneficiary of this activity: Is the beneficiary in grades 9-12 or have a child in grades 9-12?
Yes
No
Will any outside organization be involved in this activity? Yes No If yes, whom: Describe any advertising of the activity bearing the name(s) and/or picture(s) of student-athletes:
If item is for personal use, the autograph must be personalized. Provide name of person receiving autograph. (Example: To Jim): Once any organization or person receiving an item in the form of a gift donation from Butler University, that organization or person in receipt must adhere to the following guidelines: a) Autographed items cannot be sold or used for fundraising efforts that directly or indirectly benefits a high school or two-year college prospective student-athlete; b) Autographed items cannot be provided to a high school or to a high school coach or staff member; c) Autographed items cannot be provided to a high school athlete or the parents/relatives of a high school athlete; d) Autographed items cannot be provided to a high school booster or to a high school booster club. BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ THE ABOVE NCAA RULES PERTAINING TO AUTOGRAPHED ITEM(S) AND THAT I WILL ADHERE TO THESE RULES X Signature of Organization Representative
Date
*Completion of form does not guarantee accommodation
-----------------------------------------------------------------------------------Butler University Athletics Compliance Office Use Only Permissible Activity based on NCAA Guidelines Not Permissible due to NCAA Guidelines
Compliance Office Approval
Date
Return to: Compliance Office 510 West 49th Street Indianapolis, IN 46208 [email protected]
Fax:
Educational Agency (other than grades 9-12 or junior college) Non-Profit/Charitable Agency** Butler Organization State name: NCAA School/Conference Other
**Documentation of non-profit status must accompany this form.
Name of Activity: Date of Activity: City and Site of Activity: Describe below the type of Promotional/Fundraising Activity (Attach copy of flyer, if available)
Name the beneficiary of this activity: Is the beneficiary in grades 9-12 or have a child in grades 9-12?
Yes
No
Will any outside organization be involved in this activity? Yes No If yes, whom: Describe any advertising of the activity bearing the name(s) and/or picture(s) of student-athletes:
If item is for personal use, the autograph must be personalized. Provide name of person receiving autograph. (Example: To Jim): Once any organization or person receiving an item in the form of a gift donation from Butler University, that organization or person in receipt must adhere to the following guidelines: a) Autographed items cannot be sold or used for fundraising efforts that directly or indirectly benefits a high school or two-year college prospective student-athlete; b) Autographed items cannot be provided to a high school or to a high school coach or staff member; c) Autographed items cannot be provided to a high school athlete or the parents/relatives of a high school athlete; d) Autographed items cannot be provided to a high school booster or to a high school booster club. BY SIGNING, I ACKNOWLEDGE THAT I HAVE READ THE ABOVE NCAA RULES PERTAINING TO AUTOGRAPHED ITEM(S) AND THAT I WILL ADHERE TO THESE RULES X Signature of Organization Representative
Date
*Completion of form does not guarantee accommodation
-----------------------------------------------------------------------------------Butler University Athletics Compliance Office Use Only Permissible Activity based on NCAA Guidelines Not Permissible due to NCAA Guidelines
Compliance Office Approval
Date
