Organization Information
Company Name*
 
 
Company Phone*
 
 
 
Company Background*
 
 
Company Mission Statement*
 
 
 
EIN Number*
 
 
 
 
Organization Address
 
Street 1*
 
 
Street 2
 
 
Street 3
 
 
City*
 
 
State*
 
 
Zip Code*
 
 
 
Contact Information
 
 
First Name*
 
 
Last Name*
 
 
 
Email*
 
 
 
 
 
Event Information
Event Name*
 
 
Event Date*
 
 
 
Location*
 
 
Requested Sponsorship Amount*
 
 
 
Sponsorship Deadline Date*
 
 
CT Health Prior Support?*
 
 
 
Sponsorship Levels*
 
 
 
 
Event Description*
 
 
 
 
 
Upload Supporting Documentation
Diversity Organizational Chart*
 
 
 
 
File 1
 
 
 
 
File 2
 
 
 
 
File 3