Funding Request Form

Program Organizer / Grant Requestor

Please do not use the form below to report an adverse drug event (ADE). You are encouraged to report Adverse Drug Events (ADEs) to FDA by visiting www.fda.gov/medwatch or calling 1-800-FDA-1088.

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:

Zip Code / Postal Code:

Phone:

Email 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:

Email subject:

Zip Code / Postal Code:

Phone:

Email Address:

of CE Credits Provided to attendees:

Estimated Total Program Cost:

of Exhibitors:

Funding Requested from American Regent:

of Expected Attendees:

Attendee Description:

Describe the intended use of the funds:

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:

CE Provider / Course Sponsor

Program Organizer / Grant Requestor

Federal Tax ID#:

Please check if you reside outside the US:

Payee Name / Teaching Hospital

Please enter the Payee Name and/or Teaching Hospital.

Payee Name:

Street Address:

Teaching Hospital:

Yes

Federal Tax ID#:

Enduring Material

Please enter the Enduring Material information.

Enduring Material:

Website Address:

Effective Dates

From:

To:

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

Proposal

Letter of request

Current W-9

Accreditation certificate

Budget

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