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Delta Dental > Corporate Citizenship > Community Relations > Request Grants Tue. Sep. 07, 2010
Contribution Request Form

To initiate a request for a contribution from Delta Dental, please complete and submit a Contribution Request form.
Name of the Organization:
Contact Person:
Title:
Street Address:
City:
State:
ZIP Code:
Phone:
E-mail:
Employer Identification Number:
Program Title:
Total Cost of Program:
Amount Requested:
Are you seeking other sponsors: Yes No
Please List:
Is your organization providing any of the funding for this program? Yes No
Amount:
Does this program benefit:
Children?
 Yes No
Seniors?
 Yes No
Low Income Individuals?
 Yes No
Minorities?
 Yes No
At-risk Individuals?
 Yes No
Arts?
 Yes No
Recreation?
 Yes No
Education?
 Yes No
Community Development?
 Yes No
Other?
 Yes No
Is this an ongoing program? Yes No
If yes, please indicate period of time
this program will cover.
Date funds are needed


 
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