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Smile Kit Application Non-Local
Date*
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Open the calendar popup.
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 project 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 Smile Kits requested must be in increments of 50. The minimum amount of kits you can select is 50 per toothbrush size. 
ADULT KITS (Indicate how many kits you're requesting for age 8+)*
CHILD KITS (Indicate how many kits you're requesting for 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