Omega Life Membership Foundation, Inc. Impact Fund Grant Nomination Form
All fields are required to be completed
Date of Nomination
*
-
Month
-
Day
Year
Date
Foundation Member Name
*
First Name
Last Name
Executive Summary
*
Organization Contact Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Life Member Number
*
Life Member Region
*
Legal Name of the Nominated Organization
*
Nominated Organization Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Nominated Organization Key Contact Name:
*
First Name
Last Name
Nominated Organization email
*
example@example.com
Nominated Organization phone number:
*
Please enter a valid phone number.
Nominated Organization website address:
*
e.g. www.organization.com
Reason for nomination
*
Upload Budget Narrative
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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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Executive Summary of Organization’s Mission and Vision (500 word max)
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Purpose of the Grant / Grant Narrative
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Measurable Anticipated Outcomes / Metrics
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Budget Narrative / Financial Justification
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Organizational Information
Signature
*
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