Corporate Sponsorship Request Form Survey

Charitable Guidelines: Arkansas Blue Cross Blue Shield is a proud supporter of our local community. For donation consideration, please fill out this form in its entirety as well as provide the necessary documentation requested. We require a 501(c)(3) tax id number and may ask for a copy of your IRS non-profit determination letter for any and all donation requests. Any organization without a valid 501(c)(3) tax id number and/or those who cannot present the required documentation will not be eligible for a donation. Completion of this form does not guarantee a donation. Arkansas Blue Cross Blue Shield Donations are solely awarded at the Corporate Contributions Committee's discretion.

When you encounter a question in the survey that you are unable to answer, please indicate "Not available" in the required fields.

1.Organization's Name(Required.)

2.Organization Contact (First Name)(Required.)

3.Last Name(Required.)

4.Title(Required.)

5.Email Address(Required.)

6.Contact Number(Required.)

7.Organization's Mailing Address(Required.)

Address 1 (Street Name and Number)

Address 2 (Suite Number)

City

State Abbreviation

Zip Code

8.Organization's Mission Statement

9.Organization's Website(Required.)

10.Please inform us how you learned about the Arkansas Blue Cross and Blue Shield sponsorship opportunity. If an ABCBS employee referred you, please provide their name.(Required.)

11.When is the deadline for responding to this request?(Required.)

12.Tax ID Number(Required.)

13.Please upload your organization's annual report.

No file chosen

14.Social media links

15.What initiatives and programs will benefit from this request ?(Required.)

16.Will this request have Statewide Impact ?(Required.)

Yes