ORGANIZATION APPLICATION

Organization Name:

Address:

City:

Zip:

Contact Name:

Phone:

Email Address:

Website Address:

Requested Walk Location:

1. Is your organization a 501 (c) 3 non-profit? Yes No
2. What is your mission?

3. What specific services does your organization provide? To what population?

4. Our organization is Local (serving area in one county)
Regional (multi-county)
National (local chapter)
5a. Number of employees: Full-time Part-time
5b. Number of active volunteers  
6. Do any of your employees have fundraising experience? Yes No
If yes, please list names and titles:

7a. Do you have a board of directors? Yes No
7b. Are any of your board members Highmark employees? Yes No
If yes, please list names:

8. Please list your current fundraising events and 2012 dates for these events.

9. Have you received grants or sponsorship dollars from Highmark in the last year? Yes No
10. Does your organization carry Highmark insurance? Yes No
11. Is anyone in your organization related to a Highmark employee? Yes No
If yes, please list Highmark employee and relation to organization employee:

12. Do you have a staff person who can be the main contact and attend all meetings? Yes No
     

Highmark is a registered mark of Highmark Health Services


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