Corporate Citizenship Request Form

Corporate Citizenship Request Form

To request funding from Delta Dental, please complete the form below and attach all supporting documents.

Please Note:

We are pleased to review your request for support from eligible organizations whose mission aligns with our areas of focus.
Funding requests are accepted and reviewed on a rolling basis.
Decisions are typically communicated 4 – 8 weeks after submission.
Funding is limited to one grant per nonprofit organization per calendar year. If additional funding is required in a new calendar year, a new application must be submitted.

For more information about our Corporate Citizenship programs and initiatives, please contact corporatecitzenship@deltadentalmass.com

Request for funding, event Sponsorships or In - kind donation

Organization name*

Tax ID Number*

Today's Date*

Mailing Address*

Please include the street, city, state and zip code

Date funding, event sponsorship or in-kind donation is due?*

Contact Information

Full Name *

Title*

Phone Number *

Phone

Email Address*

Overview of Request

Event/ Program Title

Please provide a brief description of your organization and program.

Target Audience

Select all that apply

Adults

Arts

Children

Community Development

Education

Health and Well - Being

Low - Income and/or at - risk individuals

Minorities

Other

Approximately how many people do you anticipate will participate in this program?

Program Start Date

Program End Date

Please upload your W - 9 form and supporting materials related to organization/ event/ program

If having issues uploading material, please send to corporatecitizenship@deltadentalmass.com

Drag and drop files here or

Please describe what type of support you are requesting*

In - Kind Donation

Financial Support

Event Sponsorship

How will this project support Delta Dental’s mission to improve oral health and overall health for Massachusetts residents?

Amount requested from Delta Dental?

Be sure to enter a dollar amount. If requesting in - kind donation or event sponsorship, please put N/A

What is the proposed impact from DDMA involvement in sponsorship?

Has Delta Dental sponsored this program in the past?

If so, please indicate years(s) and amount of the past three sponsorships.

Do you require a logo from Delta Dental?

if so, please specify logo requirements.

How did you hear about the Delta Dental corporate citizenship program?*

Send me a copy of my responses

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