Contribution Request Form – Kelly Express Mart

Please fill out this form in its entirety and submit it at least two weeks prior to your event for full consideration of your request. We strongly support events and organizations that strive to improve our community and serve a broad range of citizens. We limit our donation budget to one contribution per organization per year, and requests must match our donation priorities. We will respond to your request by phone or email within 10 working days of submitting this application. We regret we are unable to fulfill all requests. Thank you.

Name
First Last
Address
Address City State ZIP Code
Phone
Email
Organization Requesting Contribution
Name of Event
Date of Event
MM slash DD slash YYYY
Amount or Donation Requested
Purpose of Donation/How funds will be used
Are you a Kelly Express Mart Customer?
CAPTCHA

Yes
No