Sponsorship / Donation Request - White House Clinics

Name of Event*

Name of Event

Date of Event*

Date of Event

Organization Name*

Organization Name

Mission / Purpose of Organization*

Mission / Purpose of Organization

Amount Requested*

Amount Requested

County / Area served by Organization*

County / Area served by Organization

Contact Name*

Contact Name

First Last

Email Address*

Email Address

Enter Email Confirm Email

Contact Phone Number*

Contact Phone Number

Projected Attendance*

Projected Attendance

How will the sponsorship / donation be used?*

How will the sponsorship / donation be used?

List of other sponsors for this event?*

List of other sponsors for this event?

If approved, provide the name of the payee:*

If approved, provide the name of the payee:

If approved, where should the payment be sent?*

If approved, where should the payment be sent?

Attachment - Upload Brochure

Max. file size: 50 MB.

Additional Information

Email

This field is for validation purposes and should be left unchanged.