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Donation Request Form
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Donation Request Form
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Name of individual or organization request is for:
If a monetary donation is being requested, who should the check be made payable to:
Contact Name:
Contact Phone:
Address:
City:
State:
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
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 Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
E-mail:
IRS Recognized non-profit?:
Yes
No
Bank Customer?:
Yes
No
United Way Agency?:
Yes
No
Cities or counties served:
General purpose of organization/event:
Details of Request
Amount or type of donation requested:
Date donation is needed by (minimum 2 weeks from date of request):
Brief description of the request, including how many people are estimated to be helped, how donation will be used and if low to moderate income groups will be served:
Have you contacted any other organizations for donations?:
Yes
No
Will the Bank receive publicity or recognition?:
Yes
No
Are any Premier Bank employees involved in this effort?:
Yes
No
Will Premier Bank have a booth or be able to supply bank product information at this event? :
Yes
No
Is there anything else you would like to include or clarify?: