DENTAL PUBLIC HEALTH AWARD and ENDOWMENT GRANT APPLICATION - North Carolina Dental Society Foundation

Dental Public Health Award: Nomination Form

In keeping with its work and mission to promote oral health to improve the quality of life for North Carolinians, the N.C. Dental Society Foundation is pleased to announce its Dental Public Health Award, which will be awarded with a gift of $1,500 to a deserving organization and presented at the N.C. Public Health Association’s Fall Education Conference in September 2020.

Name of Nominee Organization*
Website
Key contact of Nominee*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Nominee Organization Tax Status
- Tax exempt, 501(c)(3) charitable organization (include copy of IRS determination letter)
- Governmental tax exempt unit (include verification)
- Other, please specify below (include verification)
Fed. Tax ID# (if applicable)
If other, please specify
The Nominee has met one or more of these criteria...*
- Improved the oral health outcomes of children and/or adults
- Improved access to dental services
- Educated public on importance of preventative oral health practices
Why should this organization be recognized with the N.C. Dental Society Foundation Dental Public Health Award? (based on the boxes checked above, please elaborate in the space provided or attach a one-page single spaced document):*
Attachments (optional):
Max. file size: 50 MB.
Application may include photos, newspaper clippings, video links.