Mercyhealth Sponsorship

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

Company Name
Company Mission
Contact Person Contact Person First Last
Contact Title
Phone Phone - ### - ### ####
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
County

County Rock County Walworth County Winnebago County McHenry County Other
W-9 Form

Please submit a current W-9
Upload

Attach Files
IRS Designation

IRS Designation 501(c)(3) 501(c)(4) Federal ID# or other designation Federal ID# or other designation
Event Information
Event Name
Event Date (please note request can take up to four weeks to process) Event Date (please note request can take up to four weeks to process) / MM / DD YYYY
Start Time Start 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?
Overall Fundraising Goal $ Dollars . Cents
Amount Requesting (dollar amount or range)
What % of your dollars stays local?
How will Mercyhealth be recognized with this sponsorship?
Does this organization plan to make an additional request in the next 12 months? (Mercyhealth will only sponsor one event per organization each year).
Past Sponsorship Information
Has Mercyhealth sponsored your organization in the past?

Has Mercyhealth sponsored your organization in the past? Yes No
If yes, when? If yes, when? / MM / DD YYYY
If yes, when did Mercyhealth sponsor your organization and what for?
Attachments

Please submit sponsorship forms and additional information below.
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Attach Files

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

Attach Files

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

Attach Files

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

Mercyhealth Sponsorship

Mercyhealth Sponsorship

W-9 Form

Event Information

Past Sponsorship Information

Attachments