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
Format: (000) 000-0000.
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?
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
Date

MonthDayYear
Should be Empty: