Leadership Portland 2015-2016 Impact Project Proposal

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* 1. Please provide the following:

Organization

Executive Director Name

Contact person if different

Address

City, State and Zipcode

Email Address

Phone Number

IRS 501(c)(3) ID Number

Organization Website

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* 2. Your organization's mission:

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* 3. How long has this organization been a 501(c)(3)?

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* 4. Local organization yearly revenue:

< $50,000

$50,000 - $199,999

$200,000 - $499,999

$500,000 - $999,999

$1,000,000+

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* 5. Number of FTE:

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* 6. Impact Project Title:

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* 7. Briefly describe your Impact Project proposal (1000 characters or less)

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* 8. Why is your organization unable to complete this project? (500 characters or less)

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* 9. Do you believe this project can be accomplished within a 7 month period?

Yes

No

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* 10. If successful, how will this project be sustained within your organization? (300 characters or less)

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* 11. Who will be the main contact person for the Leadership Portland group to work with throughout this process?

Name:

Phone Number:

Email: