Name *

First Name

Last Name

Organization Phone Number *

(###)

###

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Organization Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact Phone Number *

(###)

###

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Is the organization a stand alone charity ie. not part of an umbrella organization which raises funds on behalf of specific programs or groups? *

Yes

No

Is the organization a national or international charity such as United Way or Canadian Red Cross? *

Yes

No

Are you a member in good standing, current with donations? *

Yes

No

Does the organization support this nomination and agree that funds will be used for specified purpose only? *

YES

NO

Has the organization been informed that a representative from 100 Women Who Care Kawartha Lakes may be contacting them for more info and/or to notify them of successful selection? *

YES

NO

If selected, will the contact person (or another representative) be available to speak at our NEXT meeting to describe the impact of the donated funds? *

YES

NO

Has this organization been a registered charity for a minimum of 1 year? *

Yes

No

Does the organization agree to not to give, sell, or use the 100 Women Who Care donor information for any further solicitation or fund-raising? *

YES

NO

Does the organization agree to mail income tax receipts to the donors within one month of receiving their donations? *

YES

NO

The nominating member must be at the meeting to speak on behalf of the selected organization- Will you be at the meeting and prepared to present on behalf of the organization? *

Yes

No