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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.
1.Organization Name:(Required.)
2.Organization Mailing Address:(Required.)
3.Organization Website URL and Social Media User Names (if applicable):(Required.)
4.Contact Person’s Information:(Required.)
5.Organization's 501-status:(Required.)
6.Federal Tax ID Number (If applicable):(Required.)
7.Attach W9:(Required.)
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8.Please list the date(s) of the program, event or initiative:(Required.)
9.What is your funding request amount?(Required.)
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.
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