Donation/Sponsorship Request - Lake Erie College of Osteopathic Medicine

Before proceeding, all sponsorship and donation requests must be submitted at least 90 days prior to the start of the event/project.

Organization Information

Legal Name of Organization Applying*

Should be the same as on IRS determination letter and as supplied on IRS form 990

Tax Identification Number*

Tax Exempt Certificate*

In order to receive a donation or sponsorship, the organization must be a nonprofit and charitable organization. Please provide a copy of your 501(c)(3) Federal Tax Exempt Certificate.

Accepted file types: pdf, Max. file size: 2 MB.

Organization W9*

Please provide a copy of your organizations W9.

Accepted file types: pdf, Max. file size: 2 MB.

Year Founded*

Current Annual Operating Budget*

Are you currently receiving funding from other entities?*

If yes, please identify the top three sources and the amount.*

Source	Amount

Contact Information

Executive Director/Primary Point of Contact*

First Last

Email Address*

Enter Email Confirm Email

Primary/Administrative Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Fax Number

Project Information

Project Name*

Purpose of the Grant*

Beginning of the Project/Campaign*

Ending of the Project/Campaign*

Amount requested.*

Total project cost.*

Geographic Area Served.*

Targeted Demographic.*

How will LECOM be recognized as a sponsor of this project/event?*

Are there additional opportunities to incorporate LECOM into this event (e.g. brochure distribution, on-site presence, vendor tent, etc.)*

Please upload any supporting documentation.

Files must be in PDF format. Maximum allowable size per files is 2MB.

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB, Max. files: 2.

Consent*

By checking this box, I confirm that the information I entered is accurate and truthful. I agree that by filling out this form, it does not guarantee a sponsorship or donation from the Lake Erie College of Osteopathic Medicine or any of its affiliates.

I agree.

Name

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

Sponsorship Request Form

Before proceeding, all sponsorship and donation requests must be submitted at least 90 days prior to the start of the event/project.

Organization Information

Contact Information

Project Information