Donation Request Form

Walpole Co-operative Bank is committed to supporting the organizations that are dedicated to our community. Use the form below to submit your sponsorship request.

Request Form

*Required

Organization Name

Donation Request Description

Event Date

Where does this donation benefit?

Requested Amount

Number of people directly benefiting

Age group served

Amount of annual budget

% of $ received going towards fundraising & administrative costs

Sponsorship Deadline

Will Walpole Co-operative Bank be recognized for this donation?

Yes No

If so, how?

Attach additional information regarding the sponsorship

Artwork, logo or banner deadline

Where to send or e-mail artwork, logo or banner

Organization Website Address

Organization Phone

Organization Email Address

Tax Identification Number

Address Line 1

Address Line 2

City

State/Province

Zip Code

Mission Statement

Is the organization:

A 503(c)3 organization?

Yes No

A local chapter of a national charity?

Yes No

A customer of Walpole Co-operative Bank?

Yes No

Attach your organization's W-9

Organization's Activities Focus On: (select one)

If you selected other, please list below

List any Walpole Co-operative Bank employees who volunteer for the organization

Name and Title of Contact Person

Contact Email Address

Contact Phone Number

Are you a Walpole Co-operative Bank customer?

Yes No

Acknowledgment

I have not included personal or time-sensitive information in this form such as account numbers, login information or other financial information.