Donation Request

Requesting Entity Name*

501(c)(3) or 501(c)(4)

501(c)(3)
501(c)(4)

Is the applicant a non-profit organization (IRS 501(c)(3) or (c)(4))?

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Number of Applicant's Members in CBCA*

Please enter a number greater than or equal to 0.

How many of the applicant’s members are members of the CBCA?

Amount Requested*

Purpose of Request

Additional Efforts in Pursuit of Request

What additional efforts, apart from any potential donation from the CBCA, has the applicant pursued to secure donations for the same purpose?

Volunteer History for CBCA Events

Has the applicant provided volunteers for any of CBCA’s fundraising events? If so, for how long? If not, has the applicant committed to providing volunteers?

Sources of Revenue and Expense

Does Applicant Pay Wages, Salaries or Stipends to Staff?*

True
False

Does the applicant pay wages, salaries, or stipends to any of its management or staff?

Award Stipulation*

Agree

By selecting “Agree” the applicant agrees to stipulate that any award will not be used to fund wages, salaries, stipends, or any such expenses to its management or staff.

Agreement to Provide Additional Information as 501(c)(3)*

Agree

By selecting “Agree” the applicant agrees to provide the CBCA, if requested, a copy of its most recent income statement and balance sheet.

Post Donation Documentation Agreement*

Agree

By selecting “Agree” the applicant agrees to provide the CBCA with post donation documentation verifying that CBCA’s donation was used for the purpose for which it was granted.

In-Person Presentation on Request*

Agree
Disagree

Will the applicant, if requested, be willing to make an in-person presentation to the executive board and/or membership?

Reason for Disagreeing to Presentation On Request

Please provide a description of why you, as an applicant, would not be willing to, upon request, make an in-person presentation to the executive board and/or membership.

Applicant Name*

First Last

Date*

Signature*

Donation Request Form

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