SMALL PROJECTS APPLICATION FORM
APPLICATION FORM
For acquiring dental materials/apparatus from DHIN to be used in deprived regions.
This form can be copied and mailed to DHIN. (click here for an explanation how to do this)

Information about the applicant
Name of organisation
            (institution, workgroup etc.)
Name of applicant
:


:
Organisations address

(address of the applicant /organisation, or contact address of the person applicating in name of the organisation and the function in which you are operating within this organisation.
street:
number:
postal code:
place:
telephone/fax  home:
                          work:
e-mail:
function:
Information about the institution (clinic/hospital) in the destination country for which this application serves.
Name of institution


Name of contact person


:


:
Address institution


Address:
place:
country:
telephone/fax:
e-mail:

Status health institution in the country in development
(choice a, b or c)
a.     private
b.     non-governmental
c.     state institution
Description of requested materials.

Can you give a global description of the materials or apparatus for which you ask DHIN to send them to you?
In case that you have a more specific description, please add this as an addendum to this application form.  

We need some additional information about the who’s, what’s and where’s of your project. You can give this information in a separate description added as an addendum to this application form.










DHIN-declaration of costs

For the costs made by DHIN to be able to dispose of these materials, DHIN will ask you to pay these costs.
We need information to whom we have to send this declaration of costs.
In most cases this will be the applicant him/herself. But there is a possibillity  that a third party will pay the costs of the materials.
In that case we ask you to fill out the name and address of the third party in the column on the right.

     The applicant (you)

     Another person or institution:

name:

address:
Addendum
Number of pages included as an addendum.
Number of pages added:

 If you want to copy and mail this form, act as follows:
- press keys Ctrl + A simultaneously. (=select the content of this page)
- press keys Ctrl + C simultaneously. (=copy the selected content)
- click here ( = to start your e-mail)
- When a "new message"-window has appeared, click on the message area and press keys Ctrl + V
  simultaneously (to past the form into your e-mail message)
- Fill in the form and mail it to us.