Benefactor Application

Thank you for your interest in the RWC-340B Benefactor Program. In addition to supporting our mission, participation in the benefactor program carries several benefits, including direct access to Ryan White members and a chance to educate RWC-340B members about issues related to the program.

If you are not sure which benefactor level is right for you, contact us at info@rwc340b.org. If you would prefer to complete our Benefactor Application and mail it in, click here to download the PDF application.

Company Information
Company / Organization Name:*
Address:*
Street Address City State / Province / Region ZIP / Postal Code
Phone:*
Fax:
Company logo:
Accepted file types: jpg, png, pdf, ai, eps, tif, Max. file size: 20 MB.
Please upload your hi-resolution, print-ready company logo. (Preferred formats: ai, eps, or 300dpi tif) (Maximum file size is 12MB.)
Primary Contact Information
Primary Contact Name:*
First Last
Email:*
Phone:*
Benefactor Program Levels
Select your benefactor level:*
- Diamond Membership at $35,000 annually
- Platinum Membership at $25,000 annually
- Gold Membership at $15,000 annually
- Ruby Membership at $10,000 annually
- Silver Membership at $5,000 annually
- Bronze Membership at $2,500 annually
Signature*

All benefactors and their provided content are subject to review before approval.
RWC-340B Benefactors are not voting Members of RWC-340B.
RWC-340B is a 501(c)(4) organization. Contributions to RWC-340B are not tax deductible donations for purposes of the Internal Revenue Service.

Company Information

Primary Contact Information

Benefactor Program Levels