Donation / Sponsorship Request
Please complete the following information to submit your donation or sponsorship request. Requests are typically reviewed within two weeks. To allow adequate time for review and processing, requests submitted at least 30 days before the date needed are more likely to be approved.
Individual Contact Information:
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Organization Information
Organization Name
Address (If monetary donation is approved, check will be mailed to this address):
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Event / Need By Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Dollar Amount Requested:
Tax Exempt Organization?
*
Yes
No
501 (c)(3)#
Services Requested:
Promo Items / Products Requested:
Is 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?
Please attach any supporting documents here: (Flyer, W9, Donation Request Letter, etc.)
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