Organization Name:
Address :
Website/e mail:
Phone:
Mission Statement:
The Organization serves the following population:
The donated funds would be used to:
The Organization’s current sources of funding are:
The Organization is a registered not-for-profit/charity able to provide tax receipts:
I certify that, to the best of my knowledge and belief, the statements provided above are true and correct.:
Nominating Member:
Nominating Email: