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01. CONTACT INFORMATION
Organization Name
*
*
Contact Name
*
Address
*
City
*
Postal Code
*
Phone Number
*
Please enter a 10 digit number
Email Address
*
Website
*
02. DONATION DETAILS
Event/Program Name
*
Event/Program Date
*
Event/Program Location
*
Category
Pediatrics
Healthcare
Other Charitable
Overview of Organization (2000 characters max)
*
Dollar Amount Requested
*
This event/program is benefitting (2000 characters max)
*
Audience or Participant Details (2000 characters max)
*
Indicate past Ledcor support, if any (2000 characters max)
*
Tax receipt provided?
Tax receipt provided?
Yes
Tax receipt provided?
No
Charitable Registration Number
*
Deadline for Donation
*
Comments/Additional Information (2000 characters max)
*
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