Donations and Sponsorships Request Form

  • Group or Organization Information   
    Date Request Needed:
     [None] Select a Date Delete the Date
    Name of Group or Organization:
    Street Address:
    City:
    State:
    Zip:


    Person Making the Request:
     
    Title:
    Phone:
    Email Address:
    Fax:


    Organization’s Primary Purpose/Mission:
     
    Does your group or organization hold 501(c)(3) nonprofit status?     
    Is your group or organization a customer of Bank Independent?     


    Are any Bank Independent employees involved with your group or organization?     
    If so, please list employee names:
     


    Details of Request
    Purpose of your request or name of your event:
     
    Location of event:






    Type of request (check all that apply):
       |   Amount requested: $ 
       |   Number of items requested: 




    Advertising Information 
    Will advertisement/promotions feature Bank Independent?   
    If yes, please describe:
     
    In what format would you like our logo?            Size?
    Email address to send logo: