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Health Center Fund Charitable Donation Request

2. Name of Organization*

4. Mailing Address*

6. Physical Address (if different than mailing address)

8. Contact*

9. Phone Number*

11. Email Address*

13. Is the Organization tax exempt?*

    1. Yes
    2. No

15. Annual Operating Budget*

17. Stated Purpose of Organization*

19. Target Beneficiaries *

    Please include geographic area served

21. Requested Amount of Donation*

23. How will this donation be used?*

25. Please attach any files necessary to support your request

Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field