Organization Name

Is this a registered charity or a 501(c)(3)*
Yes, this is a registered charity or a 501(c)     No, this is not a registered charity or a 501(c)

Contact Person

Email*

Phone*

Address*

City*

State*
—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Date & Time of Event*

Location of Event*

Purpose of Event*

Goods/services requested and the dollar value*

Who does this Organization benefit*

Are you or someone associated with this organization a customer of FVSBank?*
Yes, myself or someone associated with this organization is a customer of FVSBankNo, neither myself nor someone associated with this organization is a customer of FVSBank

Name

Promotional Opportunities: (Please provide evidence/details of how our organization will be acknowledged.)*

Other Supporting Information: Briefly describe why we should consider your request, event management capabilities or any other information that may influence our decision to provide support.*