Sponsorship & Contribution Application

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Organization Information

Organization Name (legal name) *

Federal Taxpayer ID Number *

Tax Status *

For-Profit

Governmental

501(3)(c)

Street Address *

City *

State *

Zip Code *

Year founded *

Mission statement *

Number of people served annually *

Website or URL (if available)

Executive Director (if applicable)

Project Contact *

Phone number *

(555) 555-5555

Contact Email *

Event / Project Information

Project/Event name *

Date Funds and/or Services are Needed *

Month

Day

Year

Is this a first-time program/event or annual? *

Event date, time and location (if applicable) *

Describe the sponsorship level requested (dollar amount) *

Has Ballad Health provided a sponsorship to your organization in the past? If so, provide the date of the event, level of sponsorship and outcome:

If "Other" please describe

If this request is granted, list any goods or services that Ballad and/or its team members will receive (i.e. dinner tickets, advertisements, etc). Please include monetary value for tax reporting purposes. *

Project Description
Using 2-3 sentences, describe your project – including the benefits of the project, length of time for the project to be completed, budget, other sources of income, etc. If requesting in-kind services, please provide detailed description of services requested.

Project Description *

Project Mission
How will your project help to improve the health of residents in our region?

How does this request support the mission of Ballad Health? *

Beneficiary
Identify the individuals or groups that will benefit from the requested contribution/sponsorship. Include location/county served and the anticipated number of individuals that will benefit or receive services as a result of the project.

Whom will the contribution/sponsorship benefit? *

Project Goals and Outcomes

What will the project accomplish? How will you measure success at accomplishing stated goals?

Documentation

Current W9 *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

501c3 verification (if applicable)

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Please upload supporting document if applicable

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

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Sponsorship & Contribution Application

About Us

Organization Information

Event / Project Information

Documentation