<center>Businesses Making a Difference Submission Form </center> /

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Layman, Diener, and Borntrager Insurance Agency is Harrisonburg’s largest locally-owned insurance agency serving the Shenandoah Valley with a wide selection of insurance products that enable local businesses to grow, and offer valley residents peace of mind.
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1.Your Information

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Phone Number*

E-mail Address*

2.School that you would like to submit for the Grant.

School Name*

Phone Number*

Street Address*

City*

State*

Zip Code*

3.Reason why does this organztion deserves a nomination. Please use 200 words or less.*

4.Will any of this grant be used to compensate an individual?

Yes or No*

If yes please explain.

5.If your project is time sensitive, please provide a deadline date for your project.

Deadline Date

6.Please enter your date of birth.

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	7.Terms and Conditions

	YES, I have read, understand, and agree to the Web site usage agreement and privacy policy.


	* represents required fields Children under the age of 13 may not submit this form.

With over 500 residents, Sunnyside and Summit Square’s close knit environments offer a unique setting that combines the best attributes of the healthcare and hospitality industries.
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Merck and Company, a global research-driven pharmaceutical company, is dedicated to putting patients first. Merck also publishes unbiased health information as a not-for-profit service.
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