Medical Grant/Sponsorship

Organization Information

Organization Name *
Tax ID *
Organization Address *
Organization City *
Organization State *
Organization Zip Code *
Representative Name *
Email *
Phone *
Program Name *
Location/Venue *
Date *
Program Address *
Program City *
Program State *
Program Zip Code *
Amount ($) Requested *
Total Program Budget *
Select the type of funds for which you are applying. *

If funded, how would you like to receive your funding? *

Instructions for Payment Processing (Include name, address and any special instructions) *
Is the program accredited by an independent, recognized accrediting body or are you seeking accreditation from such a body (e.g., ACCME, CEU, ACPE)? *

Does the program/activity have a bona fide educational or scientific purpose? *

How many years has this event/program been in existence? *
Describe the program/activity and its purpose, including the healthcare topic or disease state to be discussed. *
Describe the sponsorship benefits being offered, if any. *
Are other pharmaceutical companies also being solicited for the same or similar levels of sponsorship? *

Is the event broadly advertised (e.g., is the program intended for an audience that goes beyond a single practice or institution)? *

Composition: *

Target number of attendees: *

Other relevant information:
Will RedHill funding be used for transfers of value to healthcare providers (this includes meals, or speaker/facilitator payments)? *

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Terms *