REGISTERED CHARITY NOMINATION FORM

As a member of 100+ Women Who Care Mid-Island you have an opportunity to nominate a registered charity—located in Ladysmith, Nanaimo, Lantzville, a community in-between or Gabriola Island—to receive a donation of $10,000 or more. Simply fill out this form, and as long as you are a 100+ Women Who Care Mid-Island member, your Registered Charity Nomination Form will be active.

Your Name

First Name

Last Name

Your Email Address

Your Phone Number

I prefer not to present and have chosen the following 100+ Women Who Care Mid-Island member to present on my behalf if my Registered Charity Nomination Form is drawn.

The following member will present on my behalf if I am not at a meeting and my Registered Charity Nomination form is drawn.

Name of the registered charity you are nominating.

What is the registered charity number of the charity you have chosen?

What is the name of the registered charity's contact person?

What is the title of the registered charity contact person?

What is the email address of the contact person?

What is the phone number of the contact person?

What is the website address of the registered charity?

What is the registered charity's mission statement?

Who does the registered charity serve?

Who do members make their cheques payable to, if your registered charity is selected?

REGISTERED CHARITY NOMINATION FORM

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