Delta Dental of New Jersey Foundation, Inc.
Grant Application—Round One
The space available on this form may be insufficient for your responses. When providing attachments, please organize them in the same order as the items appear on this form. Also, we accept only typed grant applications.
- Name of Organization
______
Address
______
City, State, Zip
______
Tax Identification Number or
______
Employer Identification Number
______
2. Grant Contact Name
______
Title
______
Phone Number & Fax Number
______
______
3. Program Title
______
4. Amount Requested$
______
5. Date Funds Are Needed January 2017 or June 2017(please circle one)
______
6. Have you sought funding for this program from other sponsors? YES NO
Please list (indicate if awards are pending or have been approved):
$
______
(Organization) (Amount)
$
______
(Organization) (Amount)
$
______
(Organization) (Amount)
7. Will you be providing additional internal funding for the program? YES NO
$
______
(Amount)
8. If awarded funding only in 2017, in subsequent years what percentage of your program will
be sustainable? %
______
9. Area of program interest (check all that apply to the dental program you are applying for Delta Dental funding):
Dental Education (includes scholarship programs and children’s programs)
Dental Care for Developmentally Disabled Populations
Dental Care for Children (0-17 years old)
Dental Care for Senior Citizens (65+ years old)
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10. If your entity is a dental clinic (only provide totals for the population(s) your grant request
will serve; answers should pertain to Delta Dental grant only):
Approximately how many developmentally disabled persons will be served:
______
Approximately how many children will be served:
______
If your grant will be serving children, please circle what age group it will be serving:
0-3 years old/ 4-17 years old
Approximately how many senior citizens (65+) will be served:
______
If your entity is a school (answers should pertain to Delta Dental grant only):
Approximately how many students will be served:
______
Approximately how many scholarships (if applicable) will be awarded:
______
11. We encourage you to participate in community outreach programs such as Give Kids A Smile
Day(GKAS). Please tell us if you do participate in GKAS (if applicable). YES NO
If there are other community outreach programs you participate in, please list here:
______
______
12. Are you willing to provide Outcomes Reports on the use of the funds and the effectiveness
of the program? YES NO
13. Are you willing to accommodate an on-site visit by representatives of the Foundation, if
necessary, to review progress related to your program? YES NO
14. Previous grantees only need to supply updated information for the following. Please submit your organization’s most recent 990 Form (even if we have a previous form on file).
- Mission Statement Organizational Information
- Services Provided
- Affiliations
- Management and Board List
- A Copy of your Most Recent 990 Form (REQUIRED)
15. Please briefly describe your dental program, the population(s) it will serve, and how the Delta Dental grant funds will be utilized (dental care, supplies, equipment, labor related, scholarships, etc.).
______
______
______
______
______
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