Fundraiser Results Summary - Mario Lemieux Foundation

Name of Event*

Date Held*

Full Name of Organization*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Name*

Contact Phone Number*

Contact Email*

Total net proceeds (in USD)*

This form is to be completed and returned with the funds raised to the Mario Lemieux Foundation within 14 days of the event or activity

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Name

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