Donation Request Form

Donation Request Form

Please attach a brochure, flyer, or supporting materials describing your request with your completed form.
Date*

MonthDayYear
Contact Number*
Organization*
Address*
Contact Name*
Contact Email*
Dollar amount requested*
Project fundraising goal*
Amount received to date*
Brief description of group or organization*
Description of the donation request and its benefit/overall goal:*
Will Heart of Iowa Communications Cooperative be recognized as a sponsor for their donation?*

YesNo
Describe how Heart of Iowa will be recognized*
Brochure, flyer, or supporting materials describing your request*

Cancelof
By signing below, I acknowledge that I have read the donation request guidelines. Further, I understand that request forms are reviewed by Heart of Iowa on their schedule and not all requests will be approved.
Signature of Applicant*

Clear
Date*

MonthDayYear
Should be Empty: