Donation Request Form - New Hampshire

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Donation   R equest   F orm  
Mission  of  the  Organization:  
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________    
 
Date  of  Request:_____________________               Name  Of  Organization:  __________________________                                                              
Requested  By:  ________________________  
 
Primary  Contact  Person:  ________________  
Title:  _________________________________________  
Officers  of  Organization:  
 President:____________________________  
Vice  President:  _________________________________  
 Treasurer:____________________________  
Secretary:  _____________________________________  
 Board  members:_______________________________________________________________________  
_____________________________________________________________________________________
_____________________________________________________________________________________  
Organization  Address:  __________________________________________________________________  
Phone  Number:                                                                                                             Fax/Email  _____________________________________  
Are  any  bank  employees  part  of  this  organization?____________________________________________  
Brief  History  of  organization:_____________________________________________________________  
_____________________________________________________________________________________
_____________________________________________________________________________________            
Brief  explanation  of  organization’s  objectives:  _______________________________________________  
_____________________________________________________________________________________
_____________________________________________________________________________________  
Reason/event  donation  is  requested:  ______________________________________________________  
_____________________________________________________________________________________  
Date  of  event:_______________________                     Date  gift  is  needed  by:___________________________  
Who  will  the  gift  benefit?  ________________________________________________________________  
What  percentage  of  the  gift  will  be  used  for  the  event?  ________________________________________  
What  percentage  of  the  gift  will  be  used  for  the  organization’s  administrative  purposes?  _____________  
Have  we  made  previous  donations  to  this  organization?  ___________If  so,  when?  __________________  
Does  the  organization  have  a  relationship  with  the  Bank?______________________________________  
Please   f orward   t his   c ompleted   f orm   a long   w ith   y our   o rganizations   S ection   5 01   ( c)   ( 3)   t ax   e xempt  
number,   i f   a pplicable.     S end   a ll   t he   i nformation   e ither   b y   f ax   o r   m ail   t o:  
Profile   B ank  
PO   B ox   1 808  
Rochester,   N H     0 3866-­‐1808  
Fax:     6 03-­‐332-­‐2519  
Attn:     J eanette   P oulin,   A VP,   M arketing   a nd   S ales   D irector  
Donation   R equest   F orm  
Mission  of  the  Organization:  
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________    
 
Date  of  Request:_____________________               Name  Of  Organization:  __________________________                                                              
Requested  By:  ________________________  
 
Primary  Contact  Person:  ________________  
Title:  _________________________________________  
Officers  of  Organization:  
 President:____________________________  
Vice  President:  _________________________________  
 Treasurer:____________________________  
Secretary:  _____________________________________  
 Board  members:_______________________________________________________________________  
_____________________________________________________________________________________
_____________________________________________________________________________________  
Organization  Address:  __________________________________________________________________  
Phone  Number:                                                                                                             Fax/Email  _____________________________________  
Are  any  bank  employees  part  of  this  organization?____________________________________________  
Brief  History  of  organization:_____________________________________________________________  
_____________________________________________________________________________________
_____________________________________________________________________________________            
Brief  explanation  of  organization’s  objectives:  _______________________________________________  
_____________________________________________________________________________________
_____________________________________________________________________________________  
Reason/event  donation  is  requested:  ______________________________________________________  
_____________________________________________________________________________________  
Date  of  event:_______________________                     Date  gift  is  needed  by:___________________________  
Who  will  the  gift  benefit?  ________________________________________________________________  
What  percentage  of  the  gift  will  be  used  for  the  event?  ________________________________________  
What  percentage  of  the  gift  will  be  used  for  the  organization’s  administrative  purposes?  _____________  
Have  we  made  previous  donations  to  this  organization?  ___________If  so,  when?  __________________  
Does  the  organization  have  a  relationship  with  the  Bank?______________________________________  
Please   f orward   t his   c ompleted   f orm   a long   w ith   y our   o rganizations   S ection   5 01   ( c)   ( 3)   t ax   e xempt  
number,   i f   a pplicable.     S end   a ll   t he   i nformation   e ither   b y   f ax   o r   m ail   t o:  
Profile   B ank  
PO   B ox   1 808  
Rochester,   N H     0 3866-­‐1808  
Fax:     6 03-­‐332-­‐2519  
Attn:     J eanette   P oulin,   A VP,   M arketing   a nd   S ales   D irector  

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