Charitable Donation Requests All of the following information is required in order for Cornerstone Bank to consider your request. If you would like to print and complete this request form offline, please click here.Organization:Date: Organization's Contact Person: First Last Title:Mailing Address: Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone Number:Email Address: Please make sure your proposal includes the following information: A description of your organization, including its mission and major accomplishments A copy of the letter from the IRS stating your organization's 501(c)(3) status, if applicable A list of key staff, titles, and current Board of Directors including office status, if applicable Additional information can be mailed to: Cornerstone Bank Charitable Donations Committee P.O. Box 370 Southbridge, MA 01550-370 firstname.lastname@example.org Contact person's relationship to the organization: Employee Volunteer Paid Worker Fund Raiser What services are rendered by your organization?What percentage of the donation will be used to help low to moderate income individuals or families?How will this donation be used?What kind of advertising/signage and recognition will Cornerstone Bank receive, if any?Are there any other financial institutions donating at this time? If so, please list.What type of contribution are you seeking? (check one)MonetaryCornerstone Bank Promotional Item(s)Monetary Amount (please be specific):Desired Items:By what date do you need the contribution?Please submit complete proposals no less than 30 days before contribution is needed. Incomplete or late proposals may not be considered.Does your organization do business with Cornerstone Bank?To whom should the check be made payable?Signature of Applicant:Within 30 days following the event, please provide a letter or program showing how funds were used and the benefits the Bank received.