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Name of City/Community, State (Chapter Name) *

Name of Sponsoring Organization

Address *

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone *

FAX

Contact Name *

Title *

Choose All That Apply *

CorporatePartnershipOtherNon-Profit501(c)3ApplicantFor-Profit

Name of Non-Profit Fiscal Agent

Address of Non-Profit Fiscal Agent

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone

Contact Name

Title

Name of Basketball Facility/Gym

Address of Gym / Facility

Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Phone of Gym / Facility

Facility Contact Name

Do you have more than one facility / gym?

If you have more than one, we will contact you to get that information.YesNoMaybe

Name of Sponsors for Current Year *

Tell us who your sponsors are

Number of Teams for Current Year *If none, state none. We hope that future plans help you build one!

Projected MBL Season Schedule Start Date

Number of Nights Per Week

Number of Games Per Night

Projected MBL Season Schedule End Date

Give us a brief demographic description of your city/community Please attach a brief demographic description of your city/community *

(population by race, by age, etc)

Name of Person Completing This Form *

Today's Date *