Member Services

Operation Round Up Organization Application

Please complete the form and submit by clicking on the "Submit Form" button below.

Please note the following: Operation Round Up funds cannot be used to pay for electric bills. Applicants that are awarded funds will be required to have their photo taken when donations are made.

Please attach the IRS Form 501(c)(3) letter (if the applicant is a tax exempt organization), the previous year's financial statement, and a cover letter explaining, in as much detail as possible, how these monies will be used and, if a specific amount is needed, what that amount is, using the document upload tool at the end of the form. Detailed application instructions and requirements can be found on the website at www.medinaec.org/oru.

Fields with * are required fields.

Organization Information

*Contact Person:
*Title of Contact Person:
*Email Address:
*Phone Number (include area code):
*Name of Organization/Agency:

Service Address

*Address:
*City:
*State:
*Zip Code:

Maliing Address

Address:
City:
State:
Zip Code:

Is the organization/agency requesting funding income tax exempt? If "yes", a copy of the letter (Form 501c3) from the Internal Revenue Service must be uploaded using upload tool below (see Document Upload).

*Is Organization Tax Exempt?:

Please provide a copy of the organization's financial statement for the previous year using the upload file tool below (see Document Upload).

*Is the financial statement provided?:

If "no", please explain why the financial statement was not provided.:

Have you previously received funding from other entities?

*Funding from other entities?:

If yes, please list the source of funding, the amount and date you received the funds.:

Documentation Upload

IRS Form 501c3:
Previous year's financial statement:
*Cover Letter:

The information contained in this statement is for the purpose of obtaining funding from the Medina Electric Cooperative, Inc. Trust on behalf of the undersigned. The undersigned understands that the information provided herein is used in deciding to grant funding, and the undersigned represents and warrants that the information provided is true and complete and that the Medina Electric Cooperative, Inc. Trust may consider this statement as continuing to be true and correct until written notice of a change is provided. The Medina Electric Cooperative, Inc. Trust is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein.

Click here to draw your signature.

Signature of Representative

With your mouse, draw your signature. Then click Finish.

*Name of Representative:

*Date: