ICCC CHARITABLE DONATION REQUEST APPLICATION

ICCC CHARITABLE DONATION
REQUEST APPLICATION
ICCC Member Information
Full Name*

First Middle Last
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Date of Initial ICCC Membership*

MonthDayYear
Have you been an ICCC member for three consecutive years prior to date of this Charitable Donation Request Application?*

YesNo
Donation Recipient Information
Date of Charitable Event?

MonthDayYear
Amount Requested?*
Individual or Institution Name *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Business Phone *

Area CodePhone Number
Business Fax

Area CodePhone Number
Mission Statement
Charitable Donation Request Application Purpose*
Request Letter (Optional):
Upload a File

Cancelof
Send Application:
By clicking the submit button below, I cerity that all of the information provided by me on this charitable donation request application to the International Council of Corvette Clubs (ICCC) is true and complete, and I understand that if any false information, ommissions, or misrepresentations are discovered, my application will be rejected.

I also understand and agree that the terms and conditions of this charitable donation request application may be changed, with or without cause, and with or without notice, at any time by ICCC.
Electronic Signature*

First NameMiddle NameLast Name
Enter the message as it's shown*
Date

MonthDayYear
Should be Empty: