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Select your service from the drop-down list below.
First & Last Name
Health Care or Human Service Program
Program for at-risk youth, low to moderate income individuals and families
Performing Arts & Cultural Activities
Environmental & Preservation programs
Statewide (Vermont or New Hampshire)
Youth, seniors, etc.
Please review your information carefully.
Donation Type: .
Organization Name: .
Name of the Person Completing the Form: .
Donation Amount $: .
Address (Street/City/State/Zip): .
Phone Number: .
Website Address: .
Fax Number: .
Email Address: .
Have you received support from CNB
in the past?: .
Are you a 501 (c) 3 Organization?: .
Are you a local chapter of a national charitable organization?: .
Are you a CNB customer?: .
Mission statement or purpose of your organization: .
About your Activities: .
Geographic region(s) your organization serves: .
Please list any CNB employees or directors that volunteer for your organization: .
Description of the project or program for which you are requesting funds: .
Projected project cost: .
Number of people served: .
Age group served: .
Organization’s annual budget: .
Total percentage of expenses used for program activities: .
List other organizations you are collaborating with on this program or project: .
How will success of this program or project be measured?: .
How will CNB be recognized for this donation?: .
Event Date: .
Date you need to receive the funds: .
Date that artwork, logo or banner are needed (if applicable): .
Project completion date: .
Address where the funds need to be mailed: .
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