• Northeast Georgia Health System Charitable Giving Application

  • ORGANIZATION CONTACT INFORMATION

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  • EXPLAIN THE PURPOSE OF THE ORGANIZATION

  • REQUESTED CONTRIBUTION

  • Please specify the amount of the requested contribution and/or specify the in-kind services requested. 

  • In the box below, please describe how exactly the donated funds will be used, how this will benefit the health of the community and how the intended use aligns with one or more of Northeast Georgia Medical Center’s (NGMC) top five identified community needs listed here.

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  • REASON FOR REQUEST


  • STATEMENT OF UNDERSTANDING & ATTESTATION

  • By submitting this form, I attest that the information in this application and its attachments is true and accurate and that this request is not made for the purpose of influencing any governmental or legislative decision or for any unlawful purpose. Additionally, I understand that any funds awarded to the organization must be used to directly fund/support the activity stated above.

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