Sponsorship & Contribution Application

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

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 paragraph

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

Mission paragraph

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?

Benefit whom paragraph

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 paragraph

Project Goals and Outcomes

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

Documentation

Current W9

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

linespace

501c3 verification (if applicable)

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

linespace2

Please upload supporting document if applicable

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, pdf, doc, docx.

linespace3

CAPTCHA

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