Charitable Donation – United States

Please fill out the form below for your request to be considered.

"*" indicates required fields

Organization Requesting Grant

Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact

First Last

Phone

Fax

Organization Receiving Grant

Name

Address

Same as above

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact

First Last

Phone

Fax

Grant Recipient Information

Recipient Tax ID

Amount of Grant Request

*Please note that, in general, only grant requests completed in full and received by the Merit Grant Committee at least four (4) weeks prior to the start of the program will be considered.

Information For Charitable Donation

Mission or Program Title

Entity Sponsoring Humanitarian Trip or Charitable Program, e.g., name of non-profit organization

Humanitarian Trip or Program Date(s)

Humanitarian Trip or Charitable Program Destination

Mission or Program Description (include "Ship To" address in U.S. for requested product donations)

Proposed Use of Funds or Donated Product(s)

*For charitable donations, a Letter of Request must be submitted with this Grant Request.

Required Documents

The grant request will be declined unless you provide the following documentation with this form:

W9 Form (Tax ID)

Accepted file types: pdf, png, jpg, gif, doc, docx, docm, Max. file size: 50 MB.

Letter of Request, describing program objectives, purpose of the requested support, including format, scope, and number of programs covered

Max. file size: 50 MB.

Acknowledgement

By submitting this grant request you certify that to the best of your knowledge, all information set forth in this form is correct and complete, and is in compliance with Merit’s Compliance Program (attached below). You also certify that the grant is not for the purpose of inducing someone to purchase, prescribe, endorse or recommend a product, or otherwise for the purpose of obtaining or retaining business or gaining an improper business advantage.

Submission of this Grant Request and the foregoing documentation does not guarantee approval of the request. In addition, past funding does not guarantee future approval. Merit will only pay grants upon approval by the Merit Grant Committee and after the Grant Agreement has been signed by Merit and the Grant Recipient. The Merit Grant Committee reserves the right to award less than the amount requested.

Name

First Last

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this request.

Privacy Acknowledgement*

I have read and accept the privacy policy and understand how you manage my Data under GDPR. Providing personal data is voluntary, but required to process your request. We cannot process your request if information is not provided.