Excellence in Dermatology™
Excellence in Dermatologic Surgery™
Excellence in Medical Dermatology™
Excellence in Dermatopathology™

State Advocacy Grant Program Application
* Underline items are required.

Applicant Information:
State Society Name:
Telephone Number:
Email Address:
State Society Executive:
State Society President:
Type of Organization (Tax Status):
Grant Amount Requested:
Number of previously received grants:
Who will serve as the contact for the State Society's application?

Contact Information
Email Address:
Application Materials
Please upload the following items. (Word, Excel, PDF - 100 MB Max)
Narrative Description
List of State Society Officers
State Society Bylaws
W-9 Form
Form 990
State Society Budgets
Financial Audits