Corporate Giving Program – Application for Secondary School Bursary

Section A: Information about your organization

01. Organization Name:*

02. Address:*

03. Phone Number:*

04. Website:

05. Facebook page (if applicable):

06. Twitter name (if applicable):

07. Please provide any other social networking profiles your organization uses (if applicable):

08. Organization type (choose one of the following):*
An organization registered as having charitable status by the Canada Revenue Agency (CRA)A provincially registered not-for-profit organizationAn unregistered community organizationA municipality or a public institutionAn organization in the process of registering for charitable statusOther

Please specify:*

09. Registered Charity Number (if applicable):

10. You are welcome to submit additional documentations to support this application. You may add an additional document by selecting the choose file button below. Please upload the documents in a single PDF file (maximum file size permitted: 5MB) - To upload multiple documents, you will need to combine multiple documents into one PDF file.

Section B: Information about you (Contact details)

01. Name:*

02. Title:*

03. Phone Number:*

04. Email:*

05. What is your role with relation to this request?*
I am the contact for this fundraiserI work / volunteer for the organization that will receive the supportOther

Please specify:*

06. Are you the primary contact for this request?*
YesNo

Please specify appropriate contact name:*

Phone Number:*

Email:*

I have been authorized by the organization to be the contact for this request.*
I AgreeI do not agree

Section C: Agreement

By submitting this application I confirm that I have the authority to submit this request and agree to the conditions described below.

a) All information contained herein is true and accurate to the best of my knowledge;

b) Should Elexicon agree to provide support for the initiative proposed in this application, I agree that information about this initiative may be used in the promotion of Elexicon’s corporate giving program;

c) I consent to receiving email notifications regarding this request and any subsequent emails from Elexicon that relate to this request or any future grants or sponsorships associated with this initiative.

* A separate Gift Agreement, Terms and Conditions will be required to be signed off once the application has been approved and prior to release of funds. This will be provided by Elexicon upon approval of your application.

Accept Agreement*
I have read the agreement above.

I give permission to use my contact information to receive updates, future promotions, offers and communication from Elexicon Energy Inc.

Date:*

Your Name:*