Senior Management CIP Requests - Essex Savings Bank

Name of Organization: *

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

Federal Tax Identification Number (Do not include hyphen):

Program or Event (if applicable)

Are tickets Included?

Amount Requested *

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

How does your organization support LMI individuals and/or families? *

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

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