Community Grant Request Form

Please fill out this form and submit.

Name of Organization*
Address*
Street Address Address Line 2 City State 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 EDUCATION
- DENTAL SERVICE
- SUPPLIES AND EQUIPMENT
Title or Topic of Grant
Amount Requested
Total Cost of Project
Start Date*
MM slash DD slash YYYY
Completion Date*
MM slash DD slash YYYY
Does your organization have a tax-exempt stats under the Internal Revenue Code?
- Yes
- No
Please submit a letter affirming 501 9c) 3 status
Max. file size: 256 MB.
Mission Statement of the Organization
Who 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?
- Yes
- No
Please 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.
Comments
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