Requested Information

Organization Name

Address

Phone

Email

Fax

Website

Your Name / Position

Organizations Purpose or Mission Statement

What geographical area do you serve / represent?

What date do you need the contribution by if approved?

What contribution amount or product are you requesting?

How will your organization use this contribution if approved?

Most important of all, explain in detail how our contribution to you will help benefit the entire community?

Is this contribution for an eligible 501(c)(3) organization based in a community where a Dlugosch Company operates? - Choose an Option - Yes No