Branch CIP Applications - Essex Savings Bank

Name of Organization: *

Program or Event (if applicable)

Are Tickets Included?

Does your organization qualify for 501c(3) status? *

Federal Tax Identification Number:

Amount Requested *

Branch Application *

Select the Branch you wish to apply for funding.

Organization's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Organization's Website / URL

Primary Contact's Name *

First

Last

Primary Contact's Telephone Number *

Primary Contact's Title Within Organization: *

Primary Contact's Email: *

Email

Confirm Email

Do you wish to include a second contact?

Secondary Contact

First

Last

Secondary Contact's Phone

Secondary Contact's Email *

Secondary Contact's Title

Please provide information on your request *

Does your organization support the low to moderate income (LMI) community? *

Please explain how your organization supports LMI as "Other."

Please ONLY provide details on how the funds will be used to aid the LMI community.

Email *