NGHS - Global Sponsorship Form

Northeast Georgia Health System Charitable Giving Application

ORGANIZATION CONTACT INFORMATION

County of event:

Title of Event:

Name of Organization: *

Date of Event:

Date

Website Address *

Location Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Name of Contact Person *

First Name Last Name

Contact Phone Number *

Area Code Phone Number

Contact Email Address *

Is this organization a certified 501 (c) 3 corporation or other charitable organization under the U.S. Internal Revenue Code? *

EXPLAIN THE PURPOSE OF THE ORGANIZATION

Please explain the organization’s purpose, including any relevant literature or other information about the organization. *

REQUESTED CONTRIBUTION

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

Amount Requested *

In addition to, or instead of, a financial contribution, are there any in-kind services you would like to request?

Equipment Hospital Personnel Space Supplies

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.

Describe:

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. *

Please attach supporting documents outlining your event and/or support levels:

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REASON FOR REQUEST

Select the activity or program categories that best match your request. *

Charity event for not-for-profit community organization Fund for a local community health clinic Emergency funds related to local natural disaster Non-local community requesting help for response to natural disasters Community building activity (examples: physical improvements and housing, economic development, community support, environmental improvements, coalition building, community health improvement advocacy, workforce development) Community health improvement services benefitting persons living in poverty

What is the school system name?

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.

Signature: *