Grant Application

All Fields are Required. Application Deadline: October 1st
Print Application and Proceed

1. Contact Information

Name of Alliance / Organization:

Contact Person:

Street Address:

City:

State:

Zip Code:

Phone: (Day) (Evening):

Fax:

E-mail:

2. Purpose of Organization, Including a Brief History (if other than a Component or Constituent Dental Alliance):

 

3. Project Title:

Start Date:                                                 End Date:

Location of Event:

 

4. Target Audience (categories and possible number to be served):

 

5. Brief Description of Project (attach additional page(s) if more space is required):

 

6. Amount of Funds Requested:

 

7. Purpose of grant and how funds will be used (attach additional page(s) if more space is required):

 

8. Do similar projects exist in your area? If yes, how will your project differ?

 

9. Will your organization receive funding from other sources? If yes, when will it be received and how will it be used?

 

10. If applicable, please attach the following items:
A. Your organization’s most recent annual budget
B. Your IRS Tax Exemption letter (501-C-3)
C. Roster of current Board of Directors
D. Copy of last audit
E. Most recent Annual Report

Signature and Title of Authorized Individual: ________________________________________________

Date: ____________________

Submit application to: Foundation for Dental Health Education

Scan and email printed application and requested documents to: sharonwiest@gmail.com