Organization*
Today’s Date*
Address*
Contact*
Title*
Email*
Phone/Fax*
Event Type
Special Event Fundraiser Community Program
Name of Event or Fundraiser*
Day and Date*
Preferred Time*
Expected Attendance*
Location*
Mission/Purpose/Benefit*
Does the organization and/or individual have a current banking relationship(s) with North Central Bank?
Yes No
Item(s) Requested from North Central Bank (please be as specific as possible)*
How will the contribution from North Central Bank be recognized?*