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Funding Request Form
Program Organizer / Grant Requestor
Please enter the contact information for the program organizer.
Main Contact Name:
Physician Requesting Grant:
NPI Number:
State Medical License Number:
Street Address:
State / Province:
Zip Code / Postal Code:
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:
Street Address:
State / Province:
Zip Code / Postal Code:
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
Payee Name/Teaching Hospital
Please enter the Payee Name and/or the Teaching Hospital.
Payee Name:
Payee Address:
Teaching Hospital:
Tax ID #:
Enduring Material
Please enter the Enduring Material Information.
Enduring Material:
Website Address:
Effective Dates: to
Upload Documents
It is preferred if a course outline and or course brochure is attached for review. Draft forms of these documents are acceptable.
Required Documents: Grant letter and details of what grant is for, Grant Proposal, Detailed itemized budget, Completed W-9, Up-to-date Accreditor Certificate

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 4 weeks. You may check on the status of your request by emailing us at

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.

© 2018, American Regent, Inc., A Luitpold Pharmaceuticals, Inc. Company PP-CA-US-0001 (v7.0)     9/2018