EVENT PARTNERSHIP REQUEST FORM
Thank you for your interest in partnering with Supporttech Network, Inc. (SNI). Please complete the request form below and return to support@supporttechnetwork.org. You will be contacted within three business days after receipt of request.
1. ORGANIZATION & CONTACT INFORMATION
Company/Organization
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Person
*
First Name
Last Name
Title
*
Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Website
*
2. TYPE OF PARTNERSHIP REQUESTED
Check all that apply
Type of requested support/partnership
*
SNI speaker, panelist or survivor voice
SNI exhibit or information table
Breast health educational materials
Health fair or screening event participation
Co-hosting or co-branded event
Event promotion by SNI
Sponsoring an SNI event or program
Other
3. EVENT DETAILS
Event Name
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Time Zone
*
ET
CT
MT
PT
Format
*
In-Person
Virtual
Hybrid
Platform:
Zoom
Teams
Webex
Other
Venue & Address
*
Expected Attendees
*
First time hosting this event ?
*
Yes
No
Event Website or Registration Link
*
Back
Next
4. PARTNERSHIP DETAILS
What are you asking SNI to provide?
*
What will your organization provide?
*
Travel expenses covered for SNI representative?
*
Yes
No
N/A
Honorarium?
*
Yes
No
Will the event be recorded, live-streamed, or covered by media?
*
Yes
No
N/A
Are you requesting to use the SNI name or logo?
*
Yes
No
If yes, where will it appear?
*
Nearest SNI Chapter
*
5. DESCRIPTION OF PROPOSED PARTNERSHIP
Describe the event, its audience, how SNI would be involved and recognized, and how it supports Black women affected by breast cancer.
*
6. ACKNOWLEDGMENTS & SIGNATURE
Acknowledgments
*
I understand that only the SNI National Office can approve this request, and that a signed MOU is required before approval is granted.
I will not use the Sisters Network® Inc. name or logo publicly (including flyers, social media, websites, press releases, signage or event programs) until I receive written approval from the SNI National Office, and that any approved use is limited to this event and subject to SNI review.
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Printed Name
*
First Name
Last Name
Title
*
FOR SNI NATIONAL OFFICE USE ONLY
Received
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewed By
First Name
Last Name
MOU Signed
Approved On
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Status
Approved
Declined
More Info Needed
Awaiting MOU
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