Smile Kit Application Non-Local
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Smile Kit Application Non-Local
Date*
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ORGANIZATION INFORMATION
Organization name*
Street Address (Kits will ship here)*
City*
State*
ZIP *
Contact name*
Title*
Phone number*
Email address (used for contact purposes)*
PROJECT INFORMATION
Project name
Project purpose*
Does your program have an oral health education or outreach component? If yes, please explain.*
How will the kits be distributed? If in a school, which one(s)?*
Does your project target uninsured or underserved residents of Kansas? If yes, please explain.*
Project term in months*
Project start date*
Project end date*
Estimated number of direct lives affected annually (Children under 20)*
Estimated number of direct lives affected annually (Adults 20+)*
What geographic area will your project reach?*
How did you hear about the Smile Kit program?*
Which of the following grant and program criteria best applies to your program? Select only one answer.*
Type of facility or requesting organization:*


If other, please explain
What dental services are offered along with the distribution of Smile Kits?*



SMILE KIT REQUEST

The total number of kits requested must be in increments of 50. The minimum amount of kits you can enter for a category is 50. Examples: 150 adult OR 100 adult/50 youth OR 50 adult. NOT: 25 adult/25 youth OR 10 youth/40 child OR 12 adult/18 child.

Adult*
Youth kits are currently out of stock. Any number entered will be allocated to Adult kits.
Youth (ages 8-12)
Child (ages 4-7)*
Have you received kits in previous years?*

Is your organization tax exempt?*

If yes, please make sure you upload your U.S. Treasury (IRS) tax determination letter proving your organization's non-profit status below. If you do not upload it now, you'll have two days to email a current copy to corpcomm@deltadentalks.com or fax it to 316.462.3372. 

If no, a tax determination letter is not required and no additional steps are necessary.
U.S. Treasury tax determination letter/Tax exempt letter