Donation Request Form

Please email a completed W-9 form to ap@bosselman.com once you’ve completed the donation request form.
The current W-9 form can be found at w9form-online.com. When you click the link for the W9 you will be redirected to that site. You can also email the form, after it is filled out directly to ap@bosselman.com so be sure to copy and paste that address or write it down. Thank you!

Terms And Conditions

I ACCEPT THE FOLLOWING TERMS AND CONDITIONS: If my request is fulfilled by Pump & Pantry of Grand Island, Nebraska, I agree to provide recognition of Pump & Pantry, or its companies, in exchange for this donation, and, a receipt for the donation will be provided upon delivery. I understand that completion of this form does not guarantee that my organization will receive a donation. I understand that any requests must be submitted at least 30 days prior to the date the donation is needed in order to be considered, and I agree to refrain from contacting Pump & Pantry to check the status of this request.

Organization Name

What is the nearest Pump & Pantry store to your event or organization?

Is your organization a Tax Exempt 501 (C)3?

Yes No

Tax ID Number

What type of group is your organization? (i.e. School Group, Non-Profit Organization, Sports Team, Business, etc. **Please note: Religious organizations/Churches, Personal causes, Trips, and Race Cars are not supported.)

Event Name

Event Location (City & Venue)

Date of Event

Time of Event

Event Description

Has Pump & Pantry assisted your organization in the past? If so, please state how, including dates and amounts or items.

Items and Amounts Requested? (Please be specific, i.e. Cash, Gift Cards, specific items or products, and include dollar amount requested.)

How will the donation be used to help your cause?

What is your expected attendance at your event, or how many people will be helped or affected by your cause?

How will Pump & Pantry be represented at your event or in recognition of this donation? Will our logo be featured?

Will you be able to provide photographs or videos to Pump & Pantry that demonstrate our support of the event?

Yes No

Request Deadline (Please note from the Terms & Conditions agreed to above, all donation requests require 30 days lead time.)

Your Full Name

Address to send the donation, if via mail. Some items must be picked up at our Corporate Headquarters in Grand Island, Nebraska.

Email Address

Phone Number

All proposals will be reviewed within 30 days.
If your organization fits our criteria, we will respond within 30 days.

Please note: our contributions are often in the form of Gift Cards/Vouchers that can be used at Pump & Pantry locations, or, may be branded merchandise. We may also offer you the opportunity to fund raise through our company.