loop Visa ™ credit card program

Funding application
______

Thank you for your interest in our LOOP Visa™ Credit Card Program! Every two years we invite Albina non-profit customers to submit their application to be considered as a recipient organization for financial donations from the program. Please complete the application below to be considered for the 2016-2017 funding cycle.

·  The application period for the 2016-2017 funding cycle opens October 5, 2015 and closes October 23, 2015.

·  Recipient organizations are not eligible to apply for other Albina Community Bank financial support during the time they are receiving benefits from this program.

·  Recipient organizations agree to have their name / photo published on the bank’s website, in print advertising and social media.

·  Recipient organizations agree to allow Albina staff members to meet with their employees to talk about the LOOP Visa™ Credit Card program and Albina’s other products and services.

·  Recipient organizations agree to promote and encourage the use of Albina’s LOOP Visa™ Credit Card to employees, board members, and other supporters.

·  Albina Community Bank will add a link on their website to the recipient organization’s website; and asks that the recipient organization provide a link to Albina’s website on their website.

·  Applicant organizations will be voted on by Albina Community Bank customers; selected organizations will be notified on November 27, 2015.

Organization Information
Name of Organization: / Founding Year: / Tax Exemption Status:
Business Address, City, State, Zip
Telephone:
/ Web Address:
Executive Director: / Telephone:
/ Email:
Program/Project Contact: / Telephone:
/ Email:
Albina Banking Relationship Information
How long has your organization banked with Albina? / Please list any Albina employees who are involved with your organization and their roles:
LOOP Visa™ Program Support Information
Please tell us the percentage of your clients that are below 80% of the median income:
/ My organization is applying for support from the following LOOP Visa™ funding area:
Arts
Health/Social Services
Education
Environment
Economic Development
What is the primary geographic area you serve?:
What is the amount of your annual operating budget:
/ $
Please provide a brief overview of your organization and its mission:
Based on your funding area selected above (Arts, Education, etc); please describe how your organization works to support that funding area.
If approved, how will your Albina LOOP Visa™ Credit Card donation be used?
How will your organization help Albina Community Bank market this card to your clients, board members and friends? (When the cardholder selects your funding area and uses their credit card, their purchase(s) benefit your organization through Albina’s donation)
Authorization
The undersigned certifies that they are authorized to represent the organization applying for a contribution and that the information contained in this application is accurate. The undersigned agrees that if a contribution is awarded to the organization: (1) the contribution will be used for the purpose outlined in the award letter, and (2) Albina Community Bank has received nothing of material value, aside from noted sponsorship benefits, in exchange for the contribution.
Signature of Applicant:______Date: ______
Printed Name and Title: ______

Please include the following attachments with your application:

·  Nonprofit 501(c)3 letter or other non-profit designation letter

·  Current list of Board of Directors

·  Most current Annual Report

Please return your completed application and required attachments in one of the following ways:

·  By email to Elise Petersen:

·  By fax: 503-282-4691

·  By mail: Albina Community Bank, 430 NW 10th #101, Portland OR 97209

·  Or drop-off at any Albina branch office

Application deadline is Friday, October 23, 2015.

Rev. 10/2015