Donation Request

Today's Date:
Date of Event (or) Date Support is Needed: 
Name of Organization: * 
Organization's Phone Number: *  
Address (mail check to):
Phone: * 
Email: *  
Is this organization:


Is this organization a Dakotaland Community Insurance Customer?:
Does this organization receive United Way funds?:
Will Dakotaland Community Insurance receive any organization | public relations?:
If so, in what way?:
Has Dakotaland Community Insurance given support to this organization before?:
How was that support declared through a donation?: *


 
Support requested (complete all that apply):

Please provide a description for the support requested above:
For what purpose is the support to be used? :
Validation:
(For Spam Prevention)