Charitable Donations Request Complete this form if you work with a charitable organization looking for DENTALEZ products. CommentsThis field is for validation purposes and should be left unchanged.Name(Required) First Last TitleAddressCityStateZip Code(Required)Phone(Required)FaxEmail(Required) National Provider Identifier (NPI) Number: (Only if applicant's staff includes US licensed dentist or physician)Name of OrganizationWebsiteDoes your organization have 501 (c) (3) tax exempt status? Yes No Project TitlePlease provide a brief project summary, including location of where project will be based/services provided:Total Project Budget:Amount Funded to Date:Demonstration of Need:Target Population(s) to be served:Target Population Size – How many will be served:Anticipated impact of project:How will the project be implemented? Include dates of implementation and total project time period.Do patients pay for services? Yes No Does insurance cover any part of patient care: Yes No If so, is there any type of government/subsidized insurance? Yes No List any major phases of the project, if applicable:Does the project qualify as research and development as outlined by the IRS Code Section? Yes No What, if any, community or private sector collaboration will be associated with this project?What products or donations are you seeking from DENTALEZ?Have you directly or indirectly received products or donations from DENTALEZ in the past? Yes No If yes, please provide details.Attach the following mandatory items as part of this application: Principal Applicant Vitae IRS tax exempt documentation Letter(s) of support from confirmed co-sponsors and/or dental societies (where applicable). FileMax. file size: 256 MB. FileMax. file size: 256 MB. FileMax. file size: 256 MB. I herby represent and warrant that as of the date below, all information contained in this application and accompanying documents are true and accurate.(Required) MM slash DD slash YYYY Name: First Last Title:Organization:1. The products /cash must be used solely for the purposes outlined above in this application. 2. DentalEZ does not engage in the practice of dentistry or patient care. No representation shall be made that applicant is performing services on behalf of DentalEZ and shall not hold him/herself out being an employee or representative of DentalEZ. 3. Applicant agrees to indemnify, defend and hold harmless DentalEZ and its agents, representatives, officers, directors and employees from any liability, loss, cost, injury, damage or other expense that may be incurred by or claimed by any third person against it as a result of DentalEZ providing funding, any products donated or any action or non-action taken in connection with any grant-funded project. 4. DentalEZ will be recognized as a funder of any funded Project, for example, by naming DentalEZ as a supporter in program books, press materials, signage, and web sites that refer to any funded Project. All communications and press releases about any funded Project naming DentalEZ will be sent to DentalEZ for approval prior to release. Applicant acknowledges that DentalEZ reserves the right to periodically use the name or visual representations of projects it has funded for communications purposes. Applicant agrees that DentalEZ can use applicants name and logo, in publicizing any donation provided DentalEZ provide applicant the opportunity to review the disclosure in advance. 5. Applicant shall provide DentalEZ with photographs related to any funded Project for use in marketing materials, reports, newsletters, etc. 6. Applicant’s website shall recognize DentalEZ in the manner agreed to by applicant and DentalEZ.Name acts as a signature*(Required) First Last TitleDate MM slash DD slash YYYY All grant applicants will receive notification as to the outcome of their application within 30 days of DentalEZ’s receipt of a completed application.
