100+ Women Who Care Non-Profit Nomination

This form must be completed by a representative of the nominated non-profit organization to be considered for funding.

Once verified, the organization will be added to the list of pre-qualified non-profits and foundations affiliated with Pickaway County. These organizations are eligible to be presented and considered for funding at a future meeting.

Submitting this form and completing the verification process makes the organization eligible for nomination to receive up to $10,000 or more from Pickaway County 100+ Women Who Care. However, submission does not guarantee funding.

Contact Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Organization Information

Organization Name(Required)

Website

Mission/Purpose of Organization or Fund(Required)

Whom does the organization serve?(Required)

What percent of funds are allocated to providing services in Pickaway County?(Required)

If you receive an award, are you willing to send a representative to our next meeting to share how the money was, or will be spent?(Required)

Yes

Do you agree NOT to create, sell or distribute a list with our members contact information?(Required)

Yes

Do you agree NOT to solicit our members directly for further contributions?(Required)

Yes

Nominating Member Name(Required)

First Last

Signature

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