Mary Peters Trust

FOR OFFICIAL USE ONLY -

Application Reference:

Type of Award:

Amount of Award:

Date received:

House of Sport, Upper Malone Road, Belfast BT9 5LA W: www.marypeterstrust.org

T: 028 9038 3830 F: 028 9068 2757 E: info@marypeterstrust.org

RECIPIENT REPORT FORM

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	This Form can be completed in full and submitted online to The Mary Peters Trust OR, it can be printed and posted to the above address.

First Name:
Last Name:
Event:
Event date:	D M Y
Phone (mobile):
Phone (h):
Email:
Did you attend event:	Y N If you selected N please explain in Event Report box.
Event Report: please explain - A) how you benefitted from our assistance B) your result

	I agree that the Mary Peters Trust can use this information for marketing and PR purposes..
	I request that the Mary Peters Trust does not use this information for marketing and PR purposes.

	Please review the above content, then send the above information to us by clicking HERE
	OR PRINT THIS COMPLETED PAGE and post to the above address
	OR PRINT THIS UNCOMPLETED PAGE and complete and post to the above address