Organization Information

Organization Name

Mailing Address

City, State, ZIP Code

Phone Number

Website (if applicable)

Primary Contact Name

Primary Contact Email

Primary Contact Phone

Donation Request Details

Title or Name of Event/Project:

Date of Event or Required Donation

Brief description of the event/project and its purpose:

Location of event (if applicable)

Type of donation requested

Monetary Product/In-kind Other

If selecting 'other', please specify

Requested donation amount or description of items requested

How will Agwrx Cooperative’s donation be used or acknowledged

Have you received a donation from Agwrx Cooperative before?

Yes No

If yes, please describe when and what was provided

Community Impact

How does your event/project support one or more of the following areas? (Check all that apply)

Agriculture Youth development (e.g. FFA 4-H) Emergency/rescue services Community improvement

Estimated number of people served or expected attendance

Signature

Date