Sponsor Application Name of Company, Foundation or Individual * (please list the name as you want it to appear in the event materials) Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Email * Phone Sponsorship Levels * Presenting ($100,000) Visionary ($75,000) Pioneer ($50,000) Innovator ($25,000) Forerunner ($10,000) Benefactor ($7,500) Patron (Individual tickets at $500 per person) We are unable to attend and decline the Gala tickets and sponsorship benefits. Please consider our Sponsorship a 100% charitable gift. Please select your preferred method of payment: * Invoice (An invoice will be sent to the mailing address provided.) Credit Card (A UAMS representative will contact you by phone.) Check (To pay by check, see information below.) Checks should be made payable to Winthrop P. Rockefeller Cancer Institute with “Gala ‘22” in the memo line. Mailing Address: Winthrop P. Rockefeller Cancer Institute 4301 W Markham Street Slot # 623F Little Rock, AR 72205 Upload Your Logo for Website Drop a file here or click to upload Choose File Maximum upload size: 15.36MB Minimum dimensions: 884×538. The image must be a PNG with a transparent background or a vector-based file. Signature Authorizing Sponsorship Commitment Clear A receipt for your sponsorship gift will be provided, less the amount of the fair market value of goods and services offered with each sponsorship. If you are human, leave this field blank. Submit
