Community Grant Request Form Please fill out this form and submit.Name of Organization*Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Contact Name* First Last Email* Phone #*Fax #*Select a category that best describes the project/program for which support is being requested.*DENTAL EDUCATIONDENTAL SERVICESUPPLIES AND EQUIPMENTTitle or Topic of GrantAmount RequestedTotal Cost of ProjectStart Date* Date Format: MM slash DD slash YYYY Completion Date* Date Format: MM slash DD slash YYYY Does your organization have a tax-exempt stats under the Internal Revenue Code?YesNoPlease submit a letter affirming 501 9c) 3 statusMission Statement of the OrganizationWho and how many will benefit from this program/project?*How will you evaluate the success of the program/project?*Describe other grants you have received from the WMDF.Are monies being received or requested from other sources to fund this project/request?YesNoPlease explain:If the WMDF does not provide funding, how will you proceed?Write a descriptive narrative of the proposed program/project.Include your goals or objectives and the expected accomplishments. Explain how the program/project is in keeping with the mission statement of the West Michigan Dental Foundation. Provide any other information that may be helpful in guiding the board’s decision.PhoneThis field is for validation purposes and should be left unchanged.