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 *