To initiate a request for a contribution from Delta Dental, you must complete and submit a Request for Proposal form. This form can be submitted electronically (see below) or downloaded and sent to the following address:
Delta Dental of Indiana Attention: Corporate and Public Affairs Department P.O. Box 30416 Lansing, MI 48909-7916 Fax: (517) 347-5499
Name of organization:
Contact person:
Title:
Address:
City:
State:
ZIP Code:
Telephone:
Employer Identification Number:
Program title:
Total cost of program:
Amount requested:
Are you seeking other sponsors?
Yes No
Please list:
Is your organization providing any of the funding for this program? Yes No
Amount:
Does this program benefit:
YES
NO
a. Children?
b. Seniors?
c. Low income individuals?
d. Minorities?
e. At-risk individuals?
f. Arts?
g. Recreation?
h. Education?
i. Community development?
j. Other?
Is this an ongoing program? Yes No
If yes, please indicate period of time this program will cover.
Date funds are needed:
Delta Dental of Indiana Attention: Corporate and Public Affairs Department P.O. Box 30416 Lansing, Michigan 48909-7916 Fax: (517) 347-5499
