Charitable Giving and Sponsorship Application

Charitable Giving and Sponsorship Application

ABOUT YOUR ORGANIZATION

Organization Name

Website

Is your organization registered as a not-for-profit?

Select

Please confirm your organization is not on the Office of Inspector General (OIG) exclusion list.

Select

Please confirm your organization is eligible for funding per Center for Medicare & Medicaid Services (CMS) Conditions of Participation.

Select

ABOUT THE OPPORTUNITY

Please describe the event/program/sponsorship opportunity.

Date of Event

Location of Event

How does the event support the community? (Check all that apply)

Supports community health and wellness

Adds to the vitality of the Upper Valley area

Enhances a patient or a staff experience

Event is widely inclusive or organization expands access to a needed service

Organization or event helps vulnerable or marginalized population, celebrates diversity, or enhances equity

Other

Audience demographics (please describe your typical attendee/participant)

What public-facing marketing benefits are included in sponsorship? (Check all that apply)

Banner/signage

Logo and/or link on website

Social media mention

Email or print newsletter mention

Program advertisement

Participation in event

Other

Amount requested

Previously funded by APD?

Select

CONTACT INFORMATION

Name of contact person

Title

Email address

Phone number

Do you have a connection to APD?

Select

If yes, please describe

Select or enter value

APPLICANT DECLARATION

I declare that all the information in the application is to the best of my knowledge, true, and correct.
I also understand that if the information is incomplete, the application may be delayed or rejected or more information may be requested.
I acknowledge that if the information provided is misleading, any approval granted may be void.

Signature

Date

Please upload any additional marketing material that will help APD during the evaluation process.

File Upload

Drag and drop files here or

Send me a copy of my responses

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