Corporate Sponsorship Application Form

FACHC Corporate Partnership Application

Complete the application below to be considered for the FACHC Corporate Partnership Program.

About Your Organization

Name of Organization(Required)

Organization Address(Required)

Street Address Address Line 2 City State ZIP Code

Organization Phone Number(Required)

Organization Website(Required)

Brief Description of Organization(Required)

Briefly describe the product and/or service that your Organization offers.

Contact Information

Please provide contact information for the person in your organization that FACHC will reach out to regarding this application.

Contact Person Name(Required)

First Last

Contact Email Address(Required)

Email Address Confirm Email Address

Contact Phone(Required)

Phone Type(Required)

Would you like to receive Text Messages from FACHC?(Required)

Yes, I would like to OPT IN to receive text messages regarding my Corporate Sponsorship Application.

No, I would NOT like to receive text messages regarding my Corporate Sponsorship Application.

FACHC will never SPAM your phone. You will only receive text updates regarding your Corporate Sponsorship Application.

Any other information you would like FACHC to know? (Do you have an existing relationship with FACHC or any of the Member Health Centers? Have you worked with FQHCs in Florida before? Is there any other information you would like to share with FACHC that may help in the decision making process?)

Application Acknowledgement(Required)

By submitting a Corporate Partnership Application, you understand and agree that submission of this application does not constitute a partnership agreement. You further acknowledge that a representative from FACHC will reach out within 7-10 business days to finalize the application process and provide any next steps.