Promo Items Request

Application Date: *

Scope *

If regional, provide location:

Name of Organization: *

Contact Name: *

Address: *

Postal Code: *

Phone: *

Fax:

Email Address: *

Website:

Where is your organization based? *

Please indicate the type of organization this is: *

If applicable, please provide the non-profit or registered charity number:

Please provide a short paragraph or two describing your organization, including mission or mandate. *

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