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Community Donations ($1,000 or less) Application

Date +

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

County

Phone

Program Title

Total Cost of Program

Amount Requested from Delta Dental

Number of individuals to be served

Are you seeking other sponsors?

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?

Signature verifying the information submitted is true and accurate:

clear

Attach any additional supporting documentation here.