Educational Grant Request – Asia Pacific

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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 (if different than above)

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 and quantities of the Merit products required.

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 list the name and job title of the person in the organisation.

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Is payment made to the Event Organiser directly?

Yes

Is payment made to the Grant Recipient directly?*

Yes

Name of Organisation to Receive Payment

Why is payment being made to this organisation?

* A letter of authorization (if not mentioned in the event prospectus) is required.

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.

Educational Program Information

Specify what type of support the grant will be providing:*

Specific Event

Others

Event Title*

Event Date(s)*

Event Organiser(s)*

Event Description*

Event Location*

Name of the Association*

Address*

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

Details of the Support Requested:

These details should include who, what, when, and where the support will be applied.

Specific Educational Purposes of the Association*

Proposed Use of Funds or Donated Products*

Will there be other supporters of this program?*

Yes

Primary Attendees (physicians, nurses, patients, others)*

Presentation Type (live, virtual, teleconference, webcast, other)*

Required Documents

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

Course Agenda*

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

Detailed Proposed Budget*

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

Letter of Request*

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.

Max. file size: 50 MB.

Letter of Authorisation*

Letter authorizing organization to receive payment (if not the organization requesting the funds and the authorization is not clearly stated in the agenda/event prospectus).

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.

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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Educational Grant Request – Asia Pacific

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