Sponsorship Request

1. Name of Organization (Must match Tax ID)

2. Organization's Website

3. Requestor Name

3a. Requestor Title

3b. Requester Role within Organization

3c. Requestor Address

3d. Requestor Phone Number (XXXXXXXXXX)

3e. Requestor Email

4. Is your organization a tax-exempt entity pursuant to 501 on the Internal Revenue Code? (only 501(c)(3) or government nonprofit organizations may apply)

Yes

No

5. Please indicate your organization’s tax-exempt status under 26 U.S.C. § 501 - i.e. 501(c)(3), and provide your organization’s Tax Employer Identification Number.

6. Where does your organization provide services within Broward County?

6A. Please detail the services your organization provides within Broward County

7. Describe your organization, the services it provides, and the population it serves, including its mission and vision.

8. Please list the members of your organization’s governing body or its Board of Directors.

9. Is your organization a source of any health care services or referrals?

Yes

No

9a. If yes, please explain. If NO Enter N/A

10. Have you contacted anyone affiliated with Broward Health about this request?

Yes

No

10a. If yes, who? If NO Enter N/A

11. Does this sponsorship provide any good, item, or service to Broward Health (i.e. advertisement, event table, etc.)?

Yes

No

11a. If yes, what? If NO Enter N/A

12. Has the organization previously been sponsored by Broward Health or one of its facilities?

Yes

No

12a. If yes, specify the name, date, and amount of the sponsorship award. If NO enter N/A

13. Have you sponsored or supported any Broward Health events or programs?

Yes

No

13a. If yes, please specify date, amount, or type of sponsorship. If NO Enter N/A

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Request for Sponsorship Form

If you receive an error after submitting the form please note the Support ID provided in the error message and call the Service Center at (954) 847-4357 - Press 6 and enter 3579 when prompted for a PIN.

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