Sponsorship Request Form

Please note that completing this form does not guarantee Iowa Total Care’s participation or funding.

A completed W9 is required with proposed sponsorships.

Required fields are marked with an asterisk (*)

Date of Request *

Organization Name *

Organization Mission *

Organization Website

Organization contact information:

Name *

Position

Cell Phone

Office Phone

Email *

Outreach Request Reason *

Funding amount options available, if applicable

What part of the general population will this opportunity benefit? * Women Children Elderly Individuals with special needs Homeless Other, Explain

Other

Will the opportunity benefit the Medicaid population? If yes, please explain. *

Participation or funding decision need by date *

If funding request is an event and/or sponsorship, please provide the following information:

Sponsorship Type

Sponsorship or Event date, if applicable

Provide prior year event stats (i.e. attendance, sponsors/exhibitors)

Please attach your W9

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Document Attachments

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