Information entered in this form cannot be saved or returned to at a later time.
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.
Name of School/University
Federal Tax Identification Number (EIN)
Type of Scholarship:
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.