NICO Donation Request Form

NICO Donation Request Form
This form is to be used for requesting an in-kind donation or financial donation.
This request is for (choose one)
Event Title
Event Description
Scope of Reach
Event Location
Group/Association Name
Event Dates
Deadline(s) (if applicable)
Target Audience
Amount Requested (if exhibit, please attach additional levels of support)
Clinical Application (select all that apply)
Program Type

Other
Potential Number of Attendees (if applicable)
Website URL for Event (if applicable)
Event Contact Name
Event Contact Email
Event Contact Phone
Upload Agenda, or if no agenda, please include the Mission of the organization (required)

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Upload Formal Request Letter on Letterhead (required)

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Upload Levels of Support (if applicable)

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PLEASE NOTE: We will be unable to review this form without a formal letter of request and event agenda submitted.
Should be Empty: