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.
Phone
This field is for validation purposes and should be left unchanged.