Omega Life Membership Foundation, Inc. Grant Request Form
Date of Application
-
Month
-
Day
Year
Date
Organization Contact Email
Budget Narrative
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of
Legal Name: (Should be same as on IRS determination letter and as supplied on IRS Form 990.)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Federal Tax ID Number
Upload a copy of the organization’s IRS 501(c)3 Determination Letter including the Tax Identification Number or International Equivalent as a Registered Nonprofit
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Requesting Director/Chairman
First Name
Last Name
Phone Number
Please enter a valid phone number.
Contact person/title/phone number (if different from Director/ Chairman
First Name
Last Name
Address (principal/administrative office)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Program Name
Dates of Project
Amount Requested
Total Project Cost
Purpose of Grant
Measurable anticipated outcome
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Should be Empty: