Fluoridation Grant Funding

Name of Applicant*
First Last
Position of Applicant*
Phone*
Email*
Public Water System
PWSID Number*
Name of Water Treatment Plant/Utility Department*
Address of Water Treatment Plant/Utility Department*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Currently fluoridating?*
- Yes
- No
Number of residents served by PWS:*
What year did PWS start fluoridating without cessation?*
Water Source:*
Gallons per day:*
Grant Funding Request Information
Items requested for purchase:*
Amount of money requested, including shipping:*
Reason for purchase request:*
Initial Each Statement
I understand that the MOU process takes up to 60 days.*
I understand that if I purchase any items listed above before MOU has been signed by both parties, I may not be reimbursed for those items.*
I understand that I need to complete fluoridation project and submit all invoices to VDH by June 30, 2020. I will be issued a reimbursement check within 30 days of final invoice reimbursement request.*
I understand that I shall purchase, install, operate, and maintain ownership of the fluoridation equipment and utilize this item to provide optimal fluoridation in the community water supply for the entirety of the equipment’s useful life.*
Required Attachments
Estimate of equipment and/or supplies, including shipping.*

Public Water System