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Corporate Giving Program Request Form

Your application will be saved for 18 months. Instructions on how to return to your form will be on your confirmation page.

General Information

[*] indicates a required field
 Date Friday, April 18, 2014
* Organization Name
* CEO, President, or Executive Director
Contact Salutation
* Contact Person First Name
* Contact Person Last Name
* Contact Title
* Street Address
* City
* State
* Zip
Is the mailing address different?
* Address
* City
* State
* Zip
* Phone (ex: 4809877898)
* Fax (ex: 4809877898)
* Contact Email
* Web Site (ex: www.nonprofit.com)
   
Are you an Arizona-based organization?
* What percentage of funds will remain in Arizona? %

Project Information 

Please upload event marketing materials such as invitations, brochures, flyers, save-the-date announcements, sponsorship benefits, or proposal/project descriptions.
* Amount Requested in dollars (ex: 20.00)
* Project Name
Project Type
  If your project type is Program, the only fields required are Request Type and Brief Description of your request
Request Type
* Brief Description of Your Request
(1,000 characters or less)
  Golf Event
  * Entry fee per person in dollars (ex: 25.00)    * Number of Players
 
Breakfast Lunch Dinner
  * Meal cost per person in dollars (ex: 20.00)   Number of Guests
  Ticket
  * Ticket price per person - dollars (ex: 25.00)    * Number of Tickets for Sponsorship
* Event Date
* Event Time to
* Event Location

Sponsorship/Program Benefits

 Please check all that apply and upload a complete list of benefits
  Opportunity to address attendees at event
  Advertisement
 
Upload Ad Specifications
* Deadline
* Contact Name
* Email address for the contact person
* Phone (ex: 4809877898)
  Logo Inclusion Only
  * Date logo needed
  Other benefits
  * (100 characters or less)

Type of Organization and Required Materials 

Upload only the applicable materials based on your Type of Organization. If your Type of Organization is a Non-Profit, Chamber, Foundation, or Other it is required to upload the following materials:
  • Current Officers List
  • Current Board of Directors List
  • Tax Determination Letter such as 501(C)(3), 501(C)(6) or W-9
  * Type of Organization
* Tax ID# (ex: 857857565)

Certification and Submission

Please fill out this section when you are ready to submit your completed application. This submission does not guarantee approval or funding. Once your application has been submitted, you may no longer retrieve the application.
*  I certify that the above information is correct and that I am authorized by the governing board of the organization to submit the application.
* Submitted by
* Title
* Phone Number (ex: 4809877898)
 
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Additional Questions & Mailing Address

Attn: Community Relations
BLUE CROSS BLUE SHIELD OF ARIZONA
8220 N 23rd Ave
Building 1
Phoenix, AZ 85002
Within Maricopa County
Sue Glawe (602) 864-4602
Outside Maricopa County
Maribel Barrios (602) 864-5107
(For questions regarding out corporate giving program, please contact Maribel Barrios at (602) 864-5107 or MBarrios@azblue.com)