nominATION FORM Your Name * First Name Last Name Your Email Address * Your Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Your Phone (###) ### #### Your Twitter (if any) @ Your LinkedIn (if any) Nominee Name * First Name Last Name Nominee Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Nominee Phone * (###) ### #### Nominee Email * Nominee Twitter (if any) @ Nominee LinkedIn (if any) Name of case Confirmation of Class Action * I confirm the case was a class action Did this case close/settle prior to 02.28.19? * The date will help us place your nominee in the correct category. Yes No How would you describe the case? * Economic Justice Environmental Justice Racial Justice Social Justice Other In 50 words or less, what was the legal issue? * In 50 words or less, expand upon the impact of the case * Why Should Your Nominee be Inducted into the Impact Fund Class Action Hall of Fame? * Summarize for us what we need to know about the heroism and sacrifice of your nominee in 150 words or less. Thank you for your nomination. Nominees will be considered by Impact Fund Fund staff and screened for eligibility and a shortlist considered by the Impact Fund Grant Advisory committee in December. We will be in touch if we need further information. Subject to that, you can expect to hear from us again towards the end of the year. Thank you once again for participating in this process. Teddy Basham-Witherington, Deputy Director
