Donation Application Form | Passumpsic Bank

Organization Name *

Your Name *

Your Title *

Executive Director or Board President *

Address *

City *

US States *

Zip *

Phone *

Fax

Website

A 501(c)3 organization? *

A local Chapter of a national charity? *

A customer of Passumpsic Savings Bank? *

Purpose of the organization: *

Priority will be given to organizations which focus on supporting the prosperity of the communities they serve and can quantify results.

Organization's Focus (Select all that apply) *

Explain "Other"

List any Passumpsic Savings Bank employees who volunteer for your organization:

Geographic Region(s) served (Select all that apply): *

Name and brief description of the program or project for which you are requesting funding: *

Amount of request *

Number of people served *

Age group served (youth, seniors, etc.) *

List other organizations with which you are collaborating on this program or project

How will your organization measure success for this program or project?

How will Passumpsic Savings Bank be recognized for this donation? *

Date of event/program *

Date by which funding support is requested *

Date by which artwork, logo or banner needs to be received *

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