General Information

Date: Saturday, November 22, 2008
Organization Name
CEO, President or Executive Director
Contact Person and Title
Street Address
City
State
Zip
Phone	(ex. 4809877898)
Fax	(ex. 4809877898)
Email
Web Site	(ex. www.nonprofit.com)
Are you an Arizona-based organization?	YesNo
Organization Mission	(300 characters or less)

Project Information

Project Information(Complete one Corporate Giving Request Form for each program and attach the event flyer, invitation, etc.)

Amount Requested in dollars	(ex. 20.00)
Project Name
Project Type
Request Type
Brief Description of Your Request	(300 characters or less)
	Golf event

	Breakfast Lunch Dinner

	Ticket

Event Date
Event Time	: to :
Event Location
Date RSVP Needed

Benefits included in this request

(Please check all that apply and attach a complete list of benefits)

	Address attendees at event
	Advertisement
	Our logo/name in event program
	Our logo placed on your website
	Our logo/name in media and/or publicity
	Our logo on invitation or other mail material
	Other benefits

Please submit the following required materials via e-mail to corporategiving@azblue.com or mail to the address listed below.

(If the required materials were previously submitted this year, you do not need to submit them again.)

Tax ID#	(ex. 867867565)
Tax Status Code	501(C)(3)ExemptCorporationIndividual Sole ProprietorOther
What is the % ratio of Program to Administrative Costs?	%
If you are an affiliate of a national organization, what % of fund raising dollars remain in Arizona?	%
Better Business Bureau Member?	YesNo
United Way Recipient?	YesNo
What other funding sources and amounts do you anticipate for this project?	(100 characters or less)
Please note which sources are secured

	I certify that the above information is correct and that I am authorized by the governing board of this organization to submit this application.


Submitted by
Title
Phone Number	(ex. 4809877898)
	Please wait...

Attn: Community Relations BLUE CROSS BLUE SHIELD OF ARIZONA PO BOX 13466 Phoenix, AZ 85002

Within Maricopa County Sue Glawe (602) 864-4602

Outside Maricopa County Marty Laurel (602) 864-4324

All information must be complete and submitted 60 days prior to event date for consideration

(For questions regarding our corporate giving program, please contact Maribel Barrios at (602) 864-5107 or MBarrios@azblue.com )