Patronage request - Lieutenant Governor of Ontario

Organization information

Organization name*

Year founded*

How is your organization incorporated?*

Nonprofit organization (including registered charities)
Unincorporated
For-profit entity

Charitable registration number

If your organization is a registered charity, please enter its charitable registration number.

Description of organization and mission statement*

Is the organization a branch or local chapter of a larger organization?*

Yes
No

Parent organization information

Please identify the parent organization and describe its relationship to the branch or local chapter.

Scope of organization’s work*

International
National
Provincial
Municipal or local

Size of organization (number of employees, volunteers, and members)*

Website

Organization’s social media presence

Patronage request information

Reasons for patronage*

Please briefly explain your motivation in seeking the Lieutenant Governor’s patronage.

Title sought*

Honorary Patron
Other

Proposed title

The Lieutenant Governor usually receives the title Honorary Patron. If you are seeking a different title, please specify and explain.

Explanation

Other patrons

Please list any other patrons of your organization and their titles. If your organization has previously received viceregal patronage, please indicate the relevant Lieutenant Governors and years.

Additional information

Please provide any additional information that may assist in the consideration of your request.

Contact information

Contact person name*

Contact person title*

Contact person email*

Contact person phone number*

Chief Executive Officer name

Please indicate the name of your organization’s Chief Executive Officer or highest ranking official.

Chief Executive Officer email

Chief Executive Officer phone number

Organization mailing address*

Address line 1 Address line 2 Municipality Province Postal code

Final details

Audited financial statements*

Please upload your organization’s audited financial statements for the two most recent fiscal years. You may upload two PDF files of up to 2MB each.

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB, Max. files: 2.

Certification*

I certify that my organization has authorized this application for patronage from the Lieutenant Governor.

Phone

This field is for validation purposes and should be left unchanged.