| Company/Organization/Individual's Name: |
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| Company/Organization Type: |
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| If you chose other company type, please list: |
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| Brand Name: |
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| Name of agency representing company if applicable: |
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| Contact Person: |
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| Are you the: |
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| If you chose other contact type, please list: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| E-Mail: |
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| Company Website: |
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| Phone: |
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| Fax: |
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| Dates of promotion and/or length of promotion: |
, to
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| Has your company contacted the local American Heart Association office?: |
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| If yes, who? |
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| Basic concept or objective of company: |
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| If you chose other company concept, please list: |
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| What does the company believe AHA to gain from this opportunity? |
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| Is this a co-venture (a percentage or all of money from sale of a product is donated to the AHA)? |
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| What is expected of AHA to implement this program? Please provide details. |
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| Estimated income from promotion: |
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| Guaranteed income from promotion TO AHA Or % of income to AHA: |
or |
| Will other charities receive a portion of the income? |
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| If so, which charities? |
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| Does this request include AHA's name be utilized on any promotional printed materials or any other forms of publicity/communications? |
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| Does this request include one of AHA's logos be utilized on any promotional printed materials or any other forms of publicity/communications? |
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| If you chose other for logo, which logo? |
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| Where will this product be sold? |
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| Additional Information: |
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