Required fields are marked with asterisks (*)

Porcupine Gold Mines

Community Contribution Request Form

Please fill out the required information below for review by the Community Investment Committee.  Failure to provide complete information will result in a delayed response.  Should funds be approved, your organization will be required to complete a Contribution Acknowledgement Form and Contribution Post Initiative Survey, where applicable.

All fields marked with an asterisk (*) are mandatory

Please select one of the following that best describes your Organization:
 
Please select the donation category that best aligns to your event/initiative:
 
Type of Request:
 
Have you approached other Organizations for support?
 
Will this contribution be used to leverage funding?
 
How many people will benefit directly from this event/initiative?
 
Will the event/initiative enhance the development of local skills and/or business capacity?
 
Does the event/initiative aim to promote diversity and/or support underrepresented groups?
 
What beneficiary group(s) will be impacted from this event/initiative? You may select more than one.
 
Has Porcupine Gold Mines provided support to your organization in the past?
 
Will this event/initiative proceed without a contribution from Porcupine Gold Mines?
 
Would you like to submit a supporting image or file?
 

Key Contact Person

Recipient Name and Mailing Address

Province / State
Country
Is payment information same as above?