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Donation Request Form
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Date Requested:
Calendar
Today
Organization Name:
EIN/Tax ID #:
Organization Mailing Address:
City:
State:
U.S. ZIP code:
Organization Contact Name:
Title:
Phone:
Email:
The Organization is (please mark):
501 c(3) - Please include a copy of your 501 c(3).
City/Government
School
Other - please describe
Area Served/Population:
Specific Project or need that request will aid:
Type of Donation Requested:
Monetary Amount $
Other - please explain
If Monetary Amount $:
Date Needed:
Calendar
Today
Do you require our logo?:
Yes
No
If yes, what format?:
Event:
Yes - then complete the next four lines
No
Event Date:
Calendar
Today
Type of Event:
Number of People Expected to Attend:
If the event is to be advertised, please tell us how it will be done:
Other information for our consideration:
501 c(3):
Flyer:
Additional Attachment:
Direct correspondence to: Agtegra Cooperative Attn: Brittney Bulson 908 Lamont St. S | Aberdeen, SD 57401 O: 605-725-8334 | Brittney.Bulson@agtegra.com
Security code: