MDS Foundation Ambassador Grant Application

Name: *

Address 1: *

Address 2: *

City: *

State: *

Zip: *

Preferred Email Address: *

Preferred Telephone Number: *

Requested grant amount (You may request up to $2,000): *

The following dental professionals will assist me in project implementation (Dentists must be MDS members): *

Estimated total project cost, itemizing how the grant funds will be spent (Please include in-kind and/or matching grants in the total project cost): *

Date(s) and duration of your project: *

Describe the project objectives and planned activities: *

How will progress and success of the project be measured?: *

I agree, in a good faith effort, to execute the above-mentioned program as outlined in the description.

I agree to complete all pre-program materials such as a W-9 and to complete a final project report should my grant request be accepted.

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