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MDS Foundation Ambassador Grant Application

Name:
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Address 1:
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Address 2:
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City:
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State:
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Zip:
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Preferred Email Address:
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Preferred Telephone Number:
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Requested grant amount (You may request up to $2,000):
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The following dental professionals will assist me in project implementation (Dentists must be MDS members):
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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):
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Date(s) and duration of your project:
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Describe the project objectives and planned activities:
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How will progress and success of the project be measured?:
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