Charity Nomination Form

Name of organization*

Contact name*

Contact phone*

Contact email*

Address*

Website*

Mission Statement*

Population Served by the Organization*

Donated funds will be used to:

If the organization is not selected, would you like to resubmit it for nomination at our next meeting?

Yes

No

Is the organization a registered not-for-profit charity able to provide tax receipts?*

Yes

No

Charitable Registration #*

If selected, will someone from the organization be available to speak at a future meeting to describe the impact of the donated funds?

Yes

No

Has the organization been informed that a representative from 100 Men of Kawartha Lakes may be contacting them for more information and/or to notify them of successful selection?

Yes

No

Does the organization agree not to sell, give or use the 100 Men of Kawartha Lakes contacts for solicitations?*

Yes

No

Does the organization agree that none of our donation will be used for administrative costs?*

Yes

No

If selected, cheques should be made payable to:

Member Information

Nominated Organization