Partnership Confirmation (a) 
I confirm the above partnership, and I understand that I/my company will receive the benefits corresponding to the level that has been selected as set forth in the Partnership Engagement Opportunities.

I understand that my pledge balance should be received by December 31st.

I agree to provide electronic name and logo information related to the partnership (the "name and logo") as reasonably requested. I acknowledge and agree that Frontline Response is permitted to use the name and logo in connection with electronic and hard copy advertising and promotions.                                            
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Email *
Partnership Opportunities
Partnership Selection *
Name *
Company: *
Industry: *
Title: *
Primary Contact Full Name (If different than above):
Primary Contact Phone: *
Primary Contact Email: *
Donation Method  *
Installment Plan *
Affiliate Designation:  Please check all location(s) you would like to support. *
Required
Please specify the specific amount you would like to go to each location you chose above. (E.G. $5,000 toward Atlanta, $2,500 toward Macon etc...)
Notes
Typed Signature: *
Benefit details, donation statements and instructions will be sent via email to the primary contact listed above. 

We greatly appreciate your support and look forward to partnering with you this year.
A copy of your responses will be emailed to the address you provided.
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