Clark's Pump-N-Shop Donation Request
Contribution Request Application Guidelines
At Clark’s Pump-N-Shop, we are proud of our commitment and continued support of the communities that our business serves. While we would like to meet every request, we must focus our efforts on those that provide the most benefit to Clark’s Pump-N-Shop and the communities that we serve. We appreciate the time and effort of your organization and wish you success with your work.

To apply for a contribution please complete the form below and submit. Contributions will be given in the form of a product from our stores, prepaid gas cards, or cash. The average donation is in the amount of $50.00 to enable us to participate with many organizations. Please help us serve you and our community better by submitting your applications according to the following required guidelines:

1. Complete the below Clark’s Pump-N-Shop Contribution Request Application
2. Provide your organizations federally issued organization identification number (if you are a 501(c)3).
3. Submit the completed application at least 2 weeks prior to the date of the contribution needed.

Your request will be reviewed by our Contribution Committee and you will be notified of our decision within One Week of your event.

Please note: Applications which do not meet all 3 of the above requirements will automatically be declined. A completed application is not an agreement to honor your request. Contributions to organizations will not be given more than one time in a calendar year. A previous contribution does not guarantee a contribution will be offered again for a specific event or amount.

Email address *
Organization Name *
Your answer
Organization Address *
Your answer
Organization Contact Name, Phone Number or Email *
Your answer
Organization's Non-Profit Federal ID (if applicable)
Your answer
What are the goals of your organization?
Your answer
Name of event to be sponsored. *
Your answer
Purpose of the event. *
Your answer
Date of Event *
MM
/
DD
/
YYYY
Location of Event *
Your answer
How does the event benefit our community? *
Your answer
List any Clark's Pump-N-Shop employees involved in your organization or event and their roles. *
Your answer
Would you like to request *
From the above selection, in detail describe what you are requesting. *
Your answer
Have you ever received a donation from us before? *
If yes, please list type of donation and when donation was made. *
Your answer
Authorization
By submitting this request you certify you are authorized to represent the organization applying for a contribution and the information contained in this application is accurate. The submitter agrees that if a donation is awarded to the organization:

1. The contribution will be used for the purpose outlined in the application and may not be expended for any other
purpose without prior written approval from Clark’s Pump-N-Shop.
2. Clark’s Pump-N-Shop has received nothing of material value in exchange for contribution.
3. Information about the organization and the contribution may be used by Clark’s Pump-N-Shop in published materials.

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