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Funding Request Form

Program Organizer / Grant Requestor
Please enter the contact information for the program organizer.
Main Contact Name
Title
Physician Requesting Grant
NPCI Number
State Medical License Number
Organization
Street Address
City
State / Province
Zip Code / Postal Code
Phone  (ex. 123-456-7890)
E-Mail Address
Meeting start date / time
 (ex. mm/dd/yy)
Meeting end date / time
 (ex. mm/dd/yy)
For grants covering multiple meeting dates, please enter the first date and
attach a course brochure or document containing all the meeting dates.
Funding needed by date  (ex. mm/dd/yy)
Meeting location and address
CE Provider / Course Sponsor (if applicable)
Please enter the contact information for the accredited CE provider for the course.
Main Contact Name
Name
Street Address
(Where check should be mailed)
City
State / Province
Zip Code / Postal Code
Phone  (ex. 123-456-7890)
E-Mail Address
# of CE credits provided to attendees
Estimated Total Program Cost
(Please state in US Dollars only)
$
# of Exhibitors
Funding Requested from American Regent
(Please state in US Dollars only)
$
# of Expected Attendees
Attendee Description
(Select the description that most closely matches)
Describe the intended use of the funds
Name of course Faculty/Speakers
Lecture topics and course description of content
How will American Regent be recognized for support
Describe how this program fits within American Regent Guidelines on CE sponsorship:
Additional Comments/Information
Check made payable to

Federal Tax ID#
Check will be made payable to this individual/organization and must also appear on the W-9 form when submitted
Upload Documents
It is preferred if a course outline and or course brochure is attached for review. Draft forms of these documents are acceptable.
Name
Description
File
Submission
Your request for a CE sponsorship funding or grant will be reviewed and considered by American Regent's Grant Committee. Review times may vary however, typical review and response time will be 2-3 weeks. You may check on the status of your request by emailing us at argrantapplication@americanregent.com.