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Name of Organization/Group

Contact First Name

Contact Last Name

Organization Street Address

City

State

Postal Code

Phone

Briefly describe your organization's goals and objectives:

What communities and/or individuals will benefit from a contribution from Premier?

How will they benefit?

Are you an approved 501(c)(3) status organization?

Yes

Amount/type of contribution or donation you are requesting?

If seeking advertising sponsorship, how many receive the publication?

Please list ad sizes for advertising, if applicable:

As a local advertiser, we can respect deadlines. Please let us know when you need confirmation to this request:

Is any artwork required?

If yes, when is the deadline to receive it?

Please provide any additional information that may be helpful as we consider your request: