UBH Donation Request
Donation Request Form
Please fill out the following information to complete your donation request
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Tax Exempt Organization?
Yes
No
501 (c)(3)#
Dollar Amount Requested:
Services Requested:
Promo Items / Products Requested:
It this a one time request?
Yes
No
How many local individuals will benefit?
Did Uintah Basin Healthcare contribute to this cause in the past?
Yes
No
If yes, when and in what way?
Will Uintah Basin Healthcare be recognized for its contribution?
Yes
No
If yes, how? Do you need our banner or a script from us?
Is this request consistent with the vision, mission, and guiding principles of Uintah Basin Healthcare? Please include any pertinent information for your request below:
Submit
Should be Empty: