Nomination Form

The Organization is a registered not-for-profit / charity and is able to issue tax receipts. Answer must be "yes" to be considered: *

Yes

No

Is this Organization directly linked to any other charities or organizations, please state any and all: *

Nominating Member Email Address:

I certify, to the best of my knowledge and belief, that the above information is correct and true.

Nominating Member Email Address: *

Nominating Member: *

If selected, cheques should be made payable to: *

If selected, will ONE person from the Organization be able to speak at the following meeting to describe the impact of the donated funds: *

Yes

No

Has this Organization ever been a recipient of any 100 Women Who Care chapter OR 100 Men Who Give a Damn chapter funding? *

Yes

No

The Organization's current sources of funding are: *

The donated funds would be used for (please be specific): *

The Organization serves the following population: *

Misson Statement: *

Organization Website: *

Address of Local Organization: *

Charity Name (in full): *