Submission Date

YYYY

Name of Member Submitting - Must give the presentation if selected

First Name

Last Name

Member's Phone Number

(###)

###

####

Member's Email Address

Member's relationship to nominated organization

Name of Charitable Organization:

Charitable Organization's EIN (Tax Number ID)

Is the Organization a registered 501 (c) (3) (IRS Tax Free Status) charitable Organization?

Please note that while a non 501 (c) (3) Organization is eligible for consideration, contributions will not be tax deductible so therefore Members will be made aware of this status prior to voting.

Address (Headquarters and where services are provided, if different) and phone number.

Organization's Website

http://

Contact Person's name, phone number and email address at nominated organization:

When was the Organization started?

Please provide the Mission Statement of the Organization

What are the current sources of funding for the Organization? Is the nominated organization under an umbrella of a larger organization? If so, what funding does it receive?

What is the Organization's approximate annual budget?

What population does the Organization serve? (Children, women, elderly, homeless, mentally ill, etc.) AND how many people will receive services annually (approximately, if known)?

How would our funds be used by the Organization? What percent would be allocated to providing services in Madison County?

Will any portion of our contribution go toward administrative fees? If so, what percentage?

The member who nominates the Organization must give the presentation. If selected, the member who gives the presentation or a representative of the Organization must be available to speak at the following general meeting to describe the impact of the donated funds. Is this agreeable?

The organization must agree NOT to sell, give, or use the 100+ Women’s contact information for solicitations by themselves or other organizations. Will this be agreeable to the organization?

If the Organization is selected by the group, to whom will the checks be made payable?

NOMINATION FORM