PMA GRANT NOMINATION

The information provided below will remain confidential and will not be shared with third parties or used for marketing or any other purposes. All members of the Steering Group have agreed and signed a confidentiality clause to that effect.

Please note, that the potential recipient of a grant will be discussed amongst the steering group and a Fifty Three Two Charity Representative.

If you are nominating someone, the details of the person nominating are kept anonymous—please do not include your name, company, or group name in the details.

You may nominate yourself.

All nominations will be reviewed and researched, so please provide as much detail as possible. Insufficient information may result in the nomination not being considered. Additional details may be required before the grant is awarded.

Please provide all information you can. Some components are required before the form can be submitted.

You can read the full grant terms and conditions at this link. Nominees must meet the guidelines outlined in this document.

Are you nominating:

YourselfSomeone else

Name of Nominee: *

Please enter the name of the individual or group you wish to receive a grant

Website of Nominee (if applicable):

Twitter/X of Nominee:

Instagram of Nominee:

TikTok of Nominee:

Why should this nominee/you be considered?*

0/600

Please note that the maximum grant given to any one recipient, in 12 months, is £1000. The Board of Fifty Three Two, may decide to give more or less than the amount suggested, once they have taken into account the answers to the questions on this form.

A grant can be refused for any reason The Board see fit, including evidence that the recipient may be involved in actions or share opinions that do not uphold the good nature of 53two and/or bring the charity into disrepute. The decision of The Board on this matter is final.

How will a grant improve mental wellbeing of yourself, an individual or a group?*

0/600

What is the total sum requested:*

Please detail what the grant will be spent on below:

	Amount
Travel
Accomodation
Food
Living Costs (Utilities etc)
Self Care/Mental Health
Education/Self Development
Work-Life Balance
Opportunity costs of Wellbeing (Reducing work hours etc.
Other: Please fill in details below.
TOTAL REQUESTED

Please detail 'Other' from the above table, if applicable:

Email of Nominee:*

example@example.com

Phone of Nominee:

If you wish to upload this information via video or audio, please answer the questions and upload in MP3 and/or MP4.

If you have any other requirements please do email us at info@53two.com

File Upload

If a nominee is successful in becoming the recipient of a grant, The Board or a representative of The Board will contact the Nominee directly. If the Nominee fails to respond to the contact for 14 days, the grant may be revoked.

Nominees will have to agree to spend the grant within the grant guidelines laid out by The Board. Spending of money outside of these guidlines is an offence.

Nominees will be expected to complete a report after 12 months of receiving the grant, detailig how it was spent, the effects and results of the grant and any other feedback.