Sponsorship Request Form

Sponsorship Request Form
Thank you for your interest in partnering with Health New England! We’re committed to being an engaged corporate citizen in the community where we live, work and raise our families. Due the volume of requests that we receive, applicants must first submit a formal application. We no longer accept unsolicited sponsorship requests by telephone, fax, mail or email.

Please do not use this form if you are applying on behalf of a nonprofit organization or public agency (e.g. 501(c)(3) charity, school, law enforcement agency, etc.). Please visit our Grant and/or Community Benefits pages to learn about and apply for a nonprofit grant or mini-grant.
Name of Organization
Organization's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Organization's Tax ID Number
Organization's W-9 Form

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Point of Contact's Information
Name

First NameLast Name
Title
Email
example@example.com
Phone Number

Area CodePhone Number
Are You Currently A Health New England Employer Group?

YesNo
Event Information
Dollar Amount Requested
Event Name
Date of Event

MonthDayYear
DateHourMinutesAM/PM Option
Address of Event

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has Your Organization Ever Received Funding From Health New England Before?

YesNo
If Yes, What Was The Amount Received?
Describe Your Event
Event's Website (if available)
Marketing Opportunities Associated with Requested Amount (Check All That Apply)

Company Logo PublicityExhibitor Table/BoothProgram Ad (company logo only; no artwork needed from us)Program Ad (custom design opportunity; artwork needed from us)Promotional GiveawaysSpeaking OpportunityVideo ComponentOther
Other Marketing Opportunities
Are There Other Sponsors Supporting This Event? If So, Please List.
Does Your Organization Have A Current Relationship With Health New England? If So, Please Describe The Relationship And Include Names of Associates With Whom You Have Worked With.
Does Your Event Support Residents Living In Any Of The Following Counties? Select All That Apply.

HampdenHampshireFranklinBerkshireWorcesterMassachusetts Statewide
Additional Supporting Documentation

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Should be Empty:

Sponsorship Request Form

Point of Contact's Information

Event Information