Educational Grant Request – 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

Type of Request*

Monetary

In-Kind Product

Amount of Grant Request*

In-Kind Product(s) Requested for Demonstration Use*

*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.

Educational Program Information

Program Title

Program Director(s)

Program Date(s)

Program Location

Program Description

Proposed Use of Funds*

Will there by other supporters of this program?

Yes

Program Attendees & Details

Primary Attendees (physicians, nurses, patients, others)

Presentation Type (live, teleconference, webcast, CD-ROM, other)

Is the educational program CME-accredited?

Yes

Accrediting Body Name

Number of Hours

Category of Credit

*For educational programs, a copy of the proposed budget 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.

Course Agenda

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

Detailed Proposed Budget

Accepted file types: pdf, png, jpg, gif, doc, docx, docm, xls, xlsx, xlsm, 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.