*Name of Organization:

*Name of Event:

*Date of Event:

*Place of Event:

*Time of Event:

Number of people this will affect:

*Contact Person Name:

*Today Date

*Contact Person Phone Number

*Contact Person E-Mail:

*Contact Person Address:

*Type of donation:

What type of donation are you asking for (ex. product, services, cash)?

*Amount of Donation Requested:

*Please briefly describe the donation request and how it will benefit the community:

*Please briefly describe how Central Region Cooperative will receive recognition:

Security code: