Donation Request

Details of Applicant

*Name of individual or organization request is for:

If a monetary donation is being requested, who should the check be made out to?

Contact Name

Contact Phone

Mailing Address

Bank of Dudley Customer?

YES NO

TAX ID/EIN if applicable

Contact Email

Details of Request

*Amount or type of donation requested:

*Description of event/usage of funds or items:

*Date Needed By

Number of items

Has your organization requested and/or received support from our bank in the past 12 months?

YES NO

Event Location (If Applicable)

*Number of people impacted:

Areas Impacted

How will this donation be acknowledged?

By submitting this request, I understand that Bank of Dudley is a community bank designed to serve our local communities. Bank of Dudley receives many requests for donations and may not be able to fund all requests. I attest that this form is completed fully and that if information is not included, my request will not be considered.