Online Contribution Request Application
Today's Date
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Month
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Day
Year
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Date of Event
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Month
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Day
Year
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Name of Organization
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact's Name
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First Name
Last Name
Contact's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact's Email
example@example.com
Brief Description of the organization (500 characters max)
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Description the funding request (1000 character max)
*
Which category would the project/program/event best fit under?
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Education
Community Development
Environment
Heath & Recreation
Heritage & Culture
Other
Describe the population served and where they are located (500 character maximum)
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Please pick the type of request
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Event sponsorship
One-time donation
Short-term project
Long-term community and/or infrastructure development project
What form of support are you requesting?
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Financial Contribution
In-Kind Donation
Volunteering
Amount requested
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Are other funding sources secured?
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Yes
No
Percentage of total budget
*
List of Board Members and their affiliations (if any)
Proof of qualifying non-profit status, including a tax exempt determination letter from the Internal Revenue Service (501c3)
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Please add any additional documentation you would like to include in this submission.
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Have you received funding from NewRange Copper Nickel, PolyMet or Teck in the past?
Yes
No
I verify that the information submitted in this form is true and accurate to the best of my knowledge.
*
Yes
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