Donation Request

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Office Use Only

Office Use Only

ENTERED	Office Use Only: ENTERED ()
ADD TO CALENDAR	ADD TO CALENDAR ()
Picked up/Mailed	Picked up/Mailed ()

Kirksville Motor Company Sponsorship \ Donation Request Form

Request is for?*

Specific Event Sponsorship \ Organization Support

Are you a current customer of Kirksville Motor Company? (Check all that apply.)*

I have purchased a vehicle from KMC in the last 3 years I have been a customer in the Service or Parts Department at KMC in the last 12 months I have not done business with KMC in the last 3 years

Type of Request*

Monetary Door Prize

Is this organization a qualified non-profit entity?*

Yes No

Organization Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Is the address listed above the same address to be used for mailing our donation?*

Yes No

Name to be used for mailing*

First Name

Last Name

Mailing address

Address Line 1

Address Line 2

City

State

ZIP Code

Attention*

First Name

Last Name

Event \ Program Name*

Enter the name of the event or program.

Event \ Program description*

Please tell us about your organization, the event or program we will be sponsoring, and who your organization helps

Make Check Payable To*

Contact Person*

First Name

Last Name

Contact Phone*

Contact Email*

Date Needed By

Date of Event

Start Time of Event

End Time of Event

Location of Event

Brochure or Flyer of Event

No File Chosen

File uploads may not work on some mobile devices.

Upload a brochure or flyer of the event.

501c3 or W9 form if applicable (KMC will need a copy prior to the actual donation)

No File Chosen

File uploads may not work on some mobile devices.

If you are a non-for-profit organization seeking a donation, we must have a copy of your W9. If you are not a non-for profit, disregard this section. Upload copy here.

DATE REQUESTED CHECK FROM OFFICE

DATE MAILED OR PICKED UP

KMC AMOUNT/ITEMS DONATED

MATCH PROGRAM AND AMOUNT

KMC CONTACT PERSON SIGNATURE