Donation Request | Parke County REMC

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Parke County REMC
5001 E US Highway 36
Rockville, IN 47872

Office Hours
Monday-Friday 7:30 am - 4:30 pm
Lobby closed from 12:00 - 1:00 pm

Donation Request (Under $100)

Please complete this form for all donation requests that are under $100. We will review the requests on the third Wednesday of every month.

Are you applying for a donation for a non-profit organization?

Yes

Non-Profit

Non-Profit Organization Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Contact Information

Contact First Name

Contact Last Name

Contact Title

Contact Email Address

Contact Cell Phone Number

Contact Work Phone Number

Have you received a donation from Parke County REMC in the past?

Yes

Requested Donation Amount

Total Donation Goal

Title of Project/Program

What is the total number of people who will benefit from the overall potential impact of the donation? Please provide an explanation, if possible.

Please describe your project in detail, including what the donation money will be used for.

Signature

Sign above

Date of Signature

Authorization

I am authorizing, to the best of my knowledge, the information stated above on this donation application is true and correct.

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