Charitable Donation - Asia Pacific

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

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Organisation Requesting Grant

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Organisation Name

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Address

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

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Primary Contact Name

First Last

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Phone

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Organisation Receiving Grant

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Primary Contact Name

First Last

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Contact Address

Same as above

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

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Phone

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Grant Recipient Information

Organisation Name

Type of Entity*

Profit

Non-Profit

Address

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

Website Address

Recipient VAT Number

Recipient Corporate Registration Number

Amount of Grant Request

Please indicate local currency.

Product Request

Please indicate the name & quantities of the Merit products requested.

To the best of your knowledge, do you know anyone who is a member of the Board of Directors, or an Executive Committee of the grant recipient entity a Merit medical customer?

Yes

PLEASE NOTE:
* 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.

* For Charitable Donations, a Letter of Request must be submitted with this Grant Request.

Charitable Donation Details

Mission or Program Title

Humanitarian Trip or Program Date(s)

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

Detailed Mission or Program Description

Humanitarian Trip or Charitable Program Destination

Proposed Use of Funds or Donated Product(s)

Will there be other supporters of this program?*

Yes

Required Documents

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

Detailed Letter of Request

Max. file size: 50 MB.

Describe program objectives, purposes of the requested support, including format, scope, number of programs covered. If Merit products are requested, need to include the details, quantities of the Merit products required and the shipping details such as the recipient organisation name and address including specific dates of arrival if applicable.

Verification of Charitable Nature

Max. file size: 50 MB.

Please upload a document verifying the charitable nature of the organization or the event / activity.

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.

Primary Contact Name

First Name Last Name

Email Address*

Date of Submission*

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.

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Charitable Donation – Asia Pacific

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Charitable Donation – Asia Pacific

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Charitable Donation Details

Required Documents

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