BCBSNE Contribution Application

Thank you for contacting Blue Cross and Blue Shield of Nebraska with your contribution request. By completing and submitting this online application, you will help to ensure your request is reviewed by our charitable contributions committee in the most timely and accurate manner possible.

Organization Name:  
Tax Status:  
Event or Program Name for which funding is requested:  
Event Date(s) or Program Duration:  
Requestor's Name and Title:  
Email Address:  
Phone Number:  
Brief Description of the Organization: 

Brief Description of the Event (include date, time, location, dress code, etc.)
or General Description of the Program for which funding is requested: 

Sponsorship Levels that are Offered or Amount Requested: (400 character limit) 

List other corporate/media sponsors if applicable: 

For event sponsorship, what will dollars raised be used for, i.e., programs, operating expenses, research, etc.? 

What percentage of dollars raised for your organization stays in Nebraska? 

How do you measure attainment of your organization's mission and the impact of your organization on the community? 

Checks should be made payable to what organization and mailed to what address? 

Relationship to BCBSNE (if any): 

Is your organization a member of the Greater Omaha Chamber of Commerce or the Chamber of Commerce in your community? 

Anything else you'd like us to know?