To make a request for a donation, please complete the form below.

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Name of Organization:

Name of Event:

Place of Event:

Time of Event:

Date of Event:

Number of people this will affect:

Contact Person Name*:

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Type of donation:

What type of donation are you asking for (ex. product, services, cash)?

Amount of Donation Requested:

Please briefly describe the donation request and how it will benefit the community:

Please briefly describe how Central Region Cooperative will receive recognition:

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Donation Request Application