This form cannot be saved - it is recommended to compile answers to all questions and be ready to complete the entire application before beginning any portion of the online submission form.

Scholarship Request

Name of School/University

Federal Tax Identification Number (EIN)

Contact Person

Mailing Address

City

State

Zip Code

County

Phone

Amount Requested from Delta Dental

Number of Scholarships this funding will provide

Total number of students in the program

Criteria used to grant Delta Dental scholarship?

How will this scholarship help expand oral health access?

How are you currently affiliated with, or have you been sponsored by Delta Dental of Wisconsin in the past?

Attach any additional supporting documentation here.