Heartland Cooperative Services
101 Parkside Dr.  Dorchester, WI 54425
715-654-5134 or 1-800-521-2021
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AGRICULTURE - INDUSTRY - RURAL LIVING
Request for Donations
Organization Name
Please use the electronic submission form below. 
Requests must be received a least one month in advance. 
Requests are considered on a first come first serve basis
Contact Phone Number, (Include area code)
Contact name
Contact email address
City
Address
State
Zip
Monetary donation amount requested
Product(s)  & quantity requested
Reason for request: I.E. What will the product or money be used for?
If this is for a event, state date and location 
Provide brief description of event
Who should the check be written to?
If product needs to be delivered please provide location and time.
City
Address
State
Zip
Delivery time
Event Date
Organization or contact address
Event Location
Requested donation is needed by what date?
All requests will be reviewed on a first come first served basis. Please submit request one month prior to event. 
Today's date
If you prefer to fill out the form by hand and mail it in please click here for a printable form.
Organization address
Contact address