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Last Name
Phone
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Message
Request a Sponsorship
Requestor First Name
Requestor Last Name
Date of Event or Activity
Length of Event
Type of Event
Is this sponsorship tied to a charitable organization?
Yes
No
Expected turn out for the event/ fundraiser
If so, which one?
Where do proceeds go?
Charitable or Tax ID Number
Title or role within the organization
Other contact name if different from requestor title:
Best phone number to call:
Email
Relation to APTC?
Current or Past Patient
Employee
Community Member
Amount Requested
Deadline for payment
- Month -
January
February
March
April
May
June
July
August
September
October
November
December
Purpose of event/fundraiser
- Day -
1
2
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If approved, what will you need from APTC besides the monetary donation?
ie: Volunteers, Print Ads, Signage, etc.
Upon request, do you have a flyer or other promotional materials available?
- Please Select -
Yes we have a flyer
No we do not have a flyer
List what is included in this sponsorship Opportunity
Other information pertinent to request:
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