Crimtech Services Ltd.

8017 Edgar Industrial Ave., Red Deer, AB T4P 3S2

Charitable Request Form

Date

Organization

Registration Number

Organization Representative (Surname/First Name)

Address (Street/City/Postal Code)

Telephone Number

Fax Number

Website (if applicable)

Nature of Request:

Date Required

Additional Information:

FOR OFFICE USE ONLY:

Approved (Yes/No)

Date of Approval

Signature

Signature