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3. How and where will the name appear in such materials? ____________________________

__________________________________________________________________________

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4.Do you have any special needs for your fundraiser, and if so, will this require help from UNM Children’s Hospital?

(See UNM Hospitals Development Office Staff Guidelines in the Guidelines Agreement.)

Briefly describe:____________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

5. Will any other businesses or organizations be contacted for donations (product or money), or assistance of any kind? If so, please list below:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

6.If you are an owner or employee of a business, and plan to donate a percentage of sales or dollar amount of sales to UNM Children’s Hospital please provide the percentage or dollar amount of sales to be donated to UNM Children’s Hospital: _________________________________________________________________________

7.Will this percentage be taken out of gross (total) sales or out of net sales (after all expenses are paid)? (circle) gross_____ net_____

8. Any additional comments? ____________________________________________________

__________________________________________________________________________

Until written permission has been granted by the Development Office, contributions may not be solicited in the name of UNM Children’s Hospital or Children's Miracle Network and the name “UNM Children’s Hospital” or “Children's Miracle Network” may not be used for any purpose.

Information provided on this form is correct and accurately describes the event/promotion.

_________________________________________________________

Sponsoring Organization SignatureDate

This form is due no later than six (6) weeks prior to the proposed promotion. Completion of this form does not assure approval. You will be contacted if further information is needed. Written response from UNM Hospital’s Development Office will be sent by mail.

If you have any questions regarding this form or your fundraising event/promotion, please contact the UNM Hospital’s Development Office at (505) 277-5685.

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Date Received: ______________________________

Reviewed by:______________________________

(Check One) Approved:_____Disapproved: _____

Date of communication back to Sponsoring Organization: ___________________________

Method of communication: _____ Phone_____E-Mail_____Fax_____Letter_____Other

Signature of Executive Director of Development, UNM Hospitals

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SignatureDate