Charitable Contributions and Sponsorships Community Support Form

Hattiesburg Clinic is pleased to provide support to numerous initiatives in our community. All community support requests must be accompanied with this application. It is extremely important that when filling out this application, your organization is as detailed and specific as possible. Prior to filling out the application, please read Hattiesburg Clinic's partnership and sponsorship guidelines in its entirety. Click HERE to read now.

Question Title

* 1. Organization Name:

Question Title

* 2. Organization Mailing Address:

Street/PO Box

City

State

Zip Code

Question Title

* 3. Organization Website URL and Social Media User Names (if applicable):

Question Title

* 4. Contact Person’s Information:

Full Name and Title (if applicable)

Email Address

Phone Number

Question Title

* 5. Organization's 501-status:

Other (Please explain)

Question Title

* 6. Federal Tax ID Number (If applicable):

Question Title

* 7. Attach W9:

(W9 must be included in order to be considered.)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

Question Title

* 8. Please list the date(s) of the program, event or initiative:

Question Title

* 9. What is your funding request amount?

Question Title

* 10. Please attach any/all sponsorship/partnership documentation, including but not limited to: advertising program dimensions, logo needs, advertisement or logo file type, ticket information and related contact information.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File