Funding Request Form
Program Organizer / Grant Requestor
Please enter the contact information for the program organizer.
Main Contact Name:
Title:
Physician Requesting Grant:
NPI Number:
State Medical License Number:
Organization:
Street Address:
City:
State / Province:
Zip Code / Postal Code:
Phone:
E-Mail Address:
Meeting Start Date / Time:
Meeting End Date / Time:
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:
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:
City:
State / Province:
Zip Code / Postal Code:
Phone:
E-Mail Address:
# of CE credits provided to attendees:
Estimated Total Program Cost:
# of Exhibitors:
Funding Requested from American Regent:
# 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#:
Please check if you reside outside the US
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.


Please utilize a Computer for form submission
To complete this form, you will not be able to use a mobile device. Please utilize a Computer for form submission.
Thank you.





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