Organization

501(c)(3) or Tax ID#

Mission Statement

Contact Person

Title

Address

Telephone

Email

Website (optional)

Date Donation is Needed (must be at least 30 days from now)

Program Area (select all that apply):

Arts & Culture
Community Health & Wellness
Co-operative Business
Diversity, Equity & Inclusion
Environment
Food & Agriculture
Local Area Schools
Local Business & Economy
Social Issues

Would donation be used for core operating support or project/event support?
Core operating supportProject/event support

What type of donation are you requesting?
CashGift CardProduct

If a requested cash donation is approved, organization agrees to submit a completed and signed Form W-9 and Vendor Form, provided by BriarPatch Food Co-op, within ten (10) business days of notice of approval. Failure to do so will render the donation null and void.

Amount Requested