APPLICATION
	
Name of Organization:

Address
	
City	Province
	Postal Code	
Phone:	Fax:	Email:	
Certificate Mailing Address (if different from above)
	
City	Province	Postal Code	
		
Primary Contact Name:	Email:	
Phone (home):	Phone (work):	Phone (cell):	
Secondary Contact Name:	Email:	
Phone (home):	Phone (work):	Phone (cell):	
	
Start Date:	
Number of Families:	
CERTIFICATES/CARDS CANNOT BE RE-SOLD OR RE-DISTRIBUTED IN ANY FORM OUTSIDE YOUR NON-PROFIT-ORGANIZATION

_______________________________	__________________________
Signature	Position

_______________________________	__________________________
Print Name	Date

Return Completed Form to:

	PROGRESSIVE FUNDRAISING

MAIL:	3595 West 31st Avenue
	Vancouver, BC  V6S 1X8

FAX:	(604) 267-9578