EIRMC Donation Request Form

Today's Date: Date Donation Needed:

Name of Organization: Contact Person: Phone Number: Alternate Number: Email Address: Address: City:

State:

Zip:

Type of Organization

Profit Non-Profit

Tax ID Number:

(*If you do not have a Tax ID, please input 00-000000.)

or

Type of Donation Needed

Service Money Materials Other

Amount Requested: Description of donation needed. (If money is needed, please specify amount.) Who will benefit from this donation? How will Eastern Idaho Regional Medical Center be recognized?

Is this request from an EIRMC employee or is an EIRMC employee affiliated with the organization?

Yes No

If Yes, name of employee:

Has your organization submitted a request in the past 12 months?

Yes No

When? List date.

Was your request approved?

Yes No

For how much?

When? List all dates.

Please enter this word in the text field below, then click Submit.

Send Reset

Copyright 1999-2009 ehc.com; All rights reserved. Terms & Conditions of Use | Privacy Statement