Nomination Form

Charity Nomination Form

First Name

Last Name

Name

Website

Contact Name

Contact Email

Contact Phone Number

Address (to mail cheques)

Charity Registration Number

Mission Statement

What population does the charitable organization serve?

How does this charity serve Burlington/Halton directly?

If you were to receive a donation from 100+WWCB, how would that donation be used?

What are the current sources of funding for the charitable organization?

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

Yes No

Questions / Comments