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

County Rock County Walworth County Winnebago County McHenry County Other
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 (please submit a current signed W9 even if you have provided one in the past )

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 an additional request in the next 12 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. This is not where you upload the W9

Attach Files

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