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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.
Community Donations ($1,000 or less) Application
Type of Funding
One-Time
In-Kind Request
Name of Organization
Federal Tax Identification Number (EIN)
501 (c) 3 Organization
Government Agency or Public School
Native American Tribal Organization
Contact Person
Mailing Address
City
State
Zip Code
Phone
Email
Program Title
Total Cost of Program
Amount Requested from Delta Dental
Number of individuals to be served
Are you seeking other sponsors?
No
Yes
If yes, please list sponsor names
and requested amount
This project specifically benefits:
At-risk children
Low income
Elderly/Seniors
Minorities
Special Needs Population
Overall health improvement (If selected please specify in box below)
Identified community need (If selected please specify in box below)
General sponsorship of event (what charitable purpose will funds ultimately be used for? Answer in box below)
How will this program/project help Delta Dental of Wisconsin fulfil its mission of improving oral health and wellness?
How will the program be modified if full funding is not received?
How will Delta Dental be recognized?
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.