Donation Request

1. Please tell us about your organization:

To be considered for a donation from Benchmark Community Bank, please provide the following information:

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1. Your name:

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2. Name of the organization making this request:

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3. Which community or communities does your organization serve?

Kenbridge

Victoria

Farmville

Crewe

Blackstone

Lawrenceville

South Hill

Chase City

Clarksville

South Boston

Halifax

Other (please specify)

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4. How can we reach you?

Mailing address:

Phone number:

Email address:

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5. Does your organization currently bank with us?

Yes

No

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6. If no, would you like information on our Community First Account?

Yes

No

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7. Please tell us about any Benchmark associates who volunteer for or belong to your organization.