Atlantic Canada Fundraiser Request Form

Organization Name*
What are you fundraising for?*
How many individuals do you anticipate will be part of your fundraising team?
Contact Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Atlantic Provinces:

Our East Coast distributor will facilitate fundraising campaigns located in the Atlantic Provinces. Should you have any questions please contact:

Dutch Co. - Josh Peters Email: info@dutchco.ca
Address (where we will deliver the product to at the end of the campaign)
Street Address*
Street Address 2
City*
Province
Postal Code*
Is the delivery location in a residential area?*
Does the delivery location have a loading dock?*
Campaign Start Date (if known)

MonthDayYear
Campaign End Date (if known)

MonthDayYear
Date
How/where did you hear about our Fundraising Program?
Anything else we should know about your request?
Should be Empty: