Disaster Relief Application

Application for Disaster Assistance Grant

Please Read First: Any AAO member who is the victim of a disaster may apply to the AAO Foundation Disaster Relief Fund for a grant to assist in restoring, repairing or reconstructing a practice facility owned by the applicant, or the dental equipment and supplies therein. The amount of the grant shall be determined at the discretion of the AAO Foundation Board.

Eligibility Requirements: An applicant must establish that he/she suffered non-reimbursed damages to his/her practice facility from a disaster. Further, the applicant must show that these damages have caused a serious financial hardship and that other sources of adequate funding are not available. Replacement of lost income from practice interruption is not an eligible reason for assistance.

Eligibility is determined on a case-by-case basis, and available funds will be distributed on a first-come, first- served basis.

Application Documentation Email Form

* First Name

* Last Name

* Email Address

* Telephone Home or Mobile

Telephone Office

Street Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

* How did you hear about the Disaster Relief Fund?

* Are you employed by a dental school or the federal dental services? Yes
No

* Corporation Type Sole Proprietorship
Partnership
Dental Support Organization
Other (e.g., s-corp, c-corp)

Corporation Type Explanation

Nature And Date Of Disaster

Briefly describe the disaster:

Amount Of Damage Suffered To Practice Facility

Structure

Equipment

Supplies

Total Damage

Insurance Coverage

Net Loss after Insurance

Insurance Company Information

Name

Address

Street Address

Address Line 2

City

State

Amount of Coverage

Deductible Amount

Agent's Name

Agent's Phone

Certification By The Applicant

I certify that I suffered a disaster to my orthodontic practice, equipment or supplies as detailed herein on this application.

I intend to continue practicing in this community after this disaster.

I certify that the information contained in this application is true and complete. I understand that a fraudulent representation or omission of any information requested in this application is grounds for immediate refusal to grant any funds under this program, and is a violation of AAO ethics rules and applicable law.

I understand that the granting of such funds is neither a right nor entitlement and that the Board of Directors of the AAO Foundation Disaster Relief Fund shall have sole discretion in determining whether I qualify for a grant.

I hereby authorize any person, firm, corporation, agency or institution to furnish to the AAO Foundation Disaster Relief Fund any and all information in its possession relative to business of any kind whatsoever. I certify that the financial information contained in this application to the AAO Foundation Disaster Relief Fund is true and complete.

I hereby request consideration for a disaster assistance grant and agree to abide by the Rules of the AAO Foundation Disaster Relief Fund.

* Signature

* Signature Date

After submission, you will be directed to a secure page to upload your accompanying documents or photos.

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