Mercyhealth Sponsorship

Please completed the following application to apply for a Mercyhealth sponsorship.

Company Name (as it appears on W9) *
Contact Person Contact Person * First Last
Phone Phone * - ### - ### ####
Email *
Address (where check is to be mailed) Address (where check is to be mailed) *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County *
Event/Activity *
Start date of event/activity Start date of event/activity * / MM / DD YYYY
Start Time Start Time * : HH MM AM/PM
End date of event/activity End date of event/activity * / MM / DD YYYY
End Time End Time * : HH MM AM/PM
Event Location *
What is the dress attire for this event *
What is the purpose/importance of this event to the organization? *
How will the events contribute to the health and wellness of participates and/or the community? *
What is your anticipated attendance for this event? *
What was your attendance last year? *
Mission/Purpose statement of the organization *
IRS Designation *

IRS Designation 501(c)(3) 501(c)(4) Federal ID# or other designation Federal ID# or other designation
Signed W9 (if this is first time request you MUST upload a SIGNED W9, if there has not been an updated W9 sent in the past 2 years, please upload one now)

Attach Files
When do you need a decision? (PLEASE NOTE: review process can take up to FOUR WEEKS) When do you need a decision? (PLEASE NOTE: review process can take up to FOUR WEEKS) * / MM / DD YYYY
Overall fundraising goal * $ Dollars . Cents
Amount requesting from Mercyhealth (dollar amount or range) *
What % of your dollars stays local? *
Has Mercyhealth donated in the past? *

Has Mercyhealth donated in the past? Yes No
If yes, when? If yes, when? / MM / DD YYYY
If yes, what was it for?
If yes, what was the amount? $ Dollars . Cents
How will Mercyhealth be recognized for its donation? *
Does this organization plan to make additional request within the next six months? (If yes, for what activity/event) *
Are you a Mercyhealth employee? *

Are you a Mercyhealth employee? Yes No
Upload a File - Please upload Sponsorship form that list all the levels that are available for your event. *

Attach Files

(Accepted file types: jpg, jpeg, png, gif, bmp, pdf, docx, doc, xlsx, xls, ppt, pptx, txt, csv, zip)