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(Used to determine your proximity to a dentist)
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Would you like to complete your treatment plan in advance of a special occasion? (e.g.: Wedding)
If so, please provide details or enter ‘No Event’ in the space provided:
Please identify the type of procedure(s) you are seeking (if unsure, please leave blank):
Emergency Dental Care
Teeth Whitening Invisalign® Dental Bridge Dentures
Implant(s) Veneers Crowns (caps) Partials
All on 4 Implants Other (Please state)
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Oral Aesthetic Advocacy Group Inc (OAAG)
Grant Applicant / Recipient Agreement

Date of Board Approval: June 1st, 2010

As an applicant, or potential recipient of a grant from the OAAG, I agree to the following terms:

   1. I certify that any funds which may be disbursed to me by the OAAG will be used only for the purpose of a cosmetic dental treatment plan.
   2. Should I not undertake the procedure within 3 months of receipt of the Grant proceeds, I will forego my award.

   3. I understand that any proceeds I may receive from the Cosmetic Dentistry Grant Program can only be applied toward Cosmetic Procedures and that I am responsible for any basic dentistry costs such as fillings, root canals, extractions and teeth cleaning.
   4. I am responsible for informing the OAAG of any change or changes in my name or address during the period of time comprised of applying for a Cosmetic Dentistry Grant, and receipt of any Grant proceeds that may be awarded.
   5. I agree that OAAG may provide my information to authorized dental practitioners, their respective staff, third-party agents, volunteers or subsidiaries, for the purpose of booking my assessment and consultation, and to communicate with me regarding the status of my grant application; and/or to perform functions such as customer service, etc.
   6. I agree to allow the OAAG to publicize the disbursement of funds to me without prior notification to me. (We will not identify the nature of your treatment.)
   7. I agree that the OAAG may use my name, as well as other independently gathered information about me that is already in the public domain.
   8. I am aware that this includes, but is not restricted to, publication in the OAAG Newsletter, Corporate Sponsorship campaign advertisements, letters and brochures.
   9. If I am awarded a Grant, I will write a thank-you letter to the Organization that acknowledges the award. The Grant proceeds will not be awarded unless/until a thank-you letter is received.

   10. I certify that I am at least 18 years of age.

Submitting an application for a Cosmetic Dentistry Grant confirms you have read, understand and agree to the terms of these guidelines and agree to comply with them.

Agree & Apply