Patronage Request Form - Lieutenant Governor of Manitoba

ORGANIZATION INFORMATION

Organization name

Year founded

How is your organization incorporated?

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

Description of organization and mission statement

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

Yes
No

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

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 Province Postal code

ANNUAL REPORT

Please upload your organization’s most recent annual report (PDF file).

Accepted file types: pdf, Max. file size: 64 MB.

Certification

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