Request — The Leesburg Blue Foundation

Request Form

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Name

First Name

Last Name

Phone

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Description of Need

Please describe the item(s) or service(s) you are requesting funds for, including quantity, purpose, and any relevant background:

What department or team within LPD is this request intended to support?

Please specify

Estimated Cost

(Attach supporting documentation such as quotes, invoices, or vendor estimates if available.)

Additional Notes

Use this section to provide any extra information that may help clarify your request.

Upon approval, who should receive the payment, and where should it be sent? (Include name, organization, mailing address, and any account or invoice numbers if applicable.)

(Include contact name, organization, and any account or invoice numbers if applicable.)

For Payment Purposes: Organization Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

For Payment Purposes: Organization Phone

(###)

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