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Community Sponsorship Request

Submit your request online:

Fill out the information below to request an AtlantiCare sponsorship.

Items with an asterisk (*) are mandatory.

Name of Organization:
*  
Address:
*  

City:
*  
County:
*  
State:
*  
Zipcode:
Is your organization a registered 501c3, or 501c4?
*  
Describe your request below:
*  
Due date for donation/sponsorship:
   *
Date of the event:
   *
Does this event honor someone? If so, enter name:
 
Event Name:
  *  
Checks made payable to:
  *  
Address to send payment:
*  

City:
*  
State:
 
Zipcode:
*  
How will the sponsorship/contribution benefit the health and/or quality of life of the residents of our region?
*  
What is the anticipated attendance of the event?
 
Contact Name:
*  
Contact Phone:
*  
Contact Extension:
Fax:
Submitted by (if other than point of contact):
Submitter email:
*  
File Upload(s):