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APPLICATION
Agency Name
Contact Name
Address

City
State Zip
Phone

Fax

Contact Email
Web site

Please describe your organization

Please describe the mission of your organization

Is your organization a 501 (c) 3 organization as
defined by the Internal Revenue Service?

Legal Incorporation

Active Board Members

Non-Discrimination Policy

Which geographical area is served by this project?

How long has your organization been in operation?

Describe your top three funding sources

What is your annual budget?

How many people does your organization serve?

What is your Administrative Expense Percentage?

Please describe how funds provided by
Loxley's would be dedicated

Loxley’s Legend Continues Program

The Loxley's Legend program is Loxley's way to give back to Local and National Charities

Loxley's will donate 5% of the restaurant check, exclusive of alcohol to each participating charity. Charities will be designated after an application process and up to three charities will be chosen.

Customers at Loxley's will be able to designate which charity will receive their donation, and will have the option to increase or add to the donated amount. To help our customers make an informed decision, charity information will be prominently displayed at each table and literature will be available and displayed at the hostess station

Please provide as much information as possible. All fields require complete answers for an application to be considered.

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Heritage Hotel - Lancaster 500 Centerville Road Lancaster, PA 17601 1-800-223-8963

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