CTO Donation / Sponsorship Request Form

Donation / Sponsorship Request Form
Date

MonthDayYear
Conlon Thompson Orthodontics appreciates the opportunity to consider new sponsorships and give back to our community! Please complete the following form at least 30 days prior to your deadline for our Sponsorship Committee to review.
What is the type of donation you are seeking?

Promotional Item DonationSponsorshipMonetary DonationSilent Auction ItemOther
Name of Applicant*

First NameLast Name
Are you or your children a patient or former patient?*

YesNo
Name of patient
Phone Number*

Area CodePhone Number
E-mail Address*
Address (if return correspondence is needed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization's Name
Team Name / Age Level
City
Please provide a brief narrative of what your donation/sponsorship request entails and what it would mean to you and the organization if chosen.
Website / Link to Event
When and Where is the event?
Are you in need of volunteers?

YesNo
If yes, is there a volunteer coordinator/contact?
Date donation/sponsorship is needed by
Amount Requested $
Make Check Payable To
Please attach a copy of the flyer or information about the event.

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