Licking Memorial Health Systems

Disclaimer & Copyright 2025 • Licking Memorial Health Systems
1320 West Main Street, Newark OH 43055 • Telephone: (220) 564-4000

Organization Information


Organization Name:*



Federal Tax ID Number:*



Organization Mailing Address
Address:*

Address 2:

City:*

State:*

ZIP code:*

Website URL:

Mission Statement:*

Does an LMHS employee serve on your organization's board?:*
Yes No
If yes, please provide name:

Please list any current business contacts with LMHS:

Requester Information
Name:*

Position within Requesting Organization:

Email:*

Phone Number:*
( ) - Second part Third part
Are you an LMHS employee?:*
Yes No
Organization Contact:*
Same as requestor information New Contact (enter below)
Name:

Position within Requesting Organization:

Email:

Community Giving Request Information
Name of Sponsorship Opportunity (Event, program, project, etc.):*

Date and Time of Event:*
Now
Number of Participants Expected:

Sponsorship Response Deadline:*
Today
Location/Venue of Sponsorship Opportunity:*

Type of sponsorship opportunity:*
Non-profit Fundraiser Athletic Program School Support Church Activity Advertising Other
Other:

Purpose and Category of Request
Summarize the purpose of your request:*

How does this align with LMHS values and mission "to improve the health of the community?":



Other:

Attach Required Documents
W-9 Form:*

Additional Information About Your Organization or Sponsorship Opportunity:

Comprehensive Sponsorship Proposal (including all sponsorship levels and benefits):*

In the event that LMHS approves the attached community giving proposal, I acknowledge and understand that LMHS is a not-for-profit health system that follows a Net-55 payment.*

(minimum):		(maximum):

Items requested:		Quantity of items requested:

Deadline for items in hand:
Today

Community