Grant & Donations | Support For Medical Science

Research Project

Educational Grant

Fellowship

Charitable Donation

Please describe what is the project and how the funds or product donation will be used *

Organization name: *

Organization type: *

501c3 Non-profit (for US only)

Other not for profit

For Profit

Contact Name: *

Contact Email Address: *

Contact Address: *

Contact Phone Number: *

Website:

Organization Tax ID:

Organization National Provider Identifier (if applicable):

Please upload W-9 form (for US only):

Please attach the following documents

Program Title: *

Amount Requested: *

Detailed description of the Program/Event: *

Additional information or notes, if any:

Please attach the following documents

1. Program/Event’s Budget Breakdown *

2. Program/Event’s Agenda or Description *

3. Official Request Letter from entity requesting the grant (i.e. on letterhead, dated & signed) *

4. Other relevant documentation (i.e. pamphlets, brochures, invitations, etc.)

Please provide the Bank Account details of where the funds should be sent to once/if request is approved [e.g., Bank Name, Account Number, SWIFT/IBAN code, etc.]:

Has your organization received support in the form of a donation or grant from MicroPort CRM in the past? *

Yes

Please confirm that you have no business, professional, personal, or other interest, (including but not limited to family members employed by MicroPort CRM or personal business interests in MicroPort CRM), that would conflict in any manner or degree with the performance of your obligations under this request or any agreement that may be entered in to as a result of this request:

If any such actual or potential conflict of interest arises you shall immediately inform the Company in writing of such conflict.

Please provide the name of your point of contact, if applicable:

Certification

By submitting this application, I acknowledge and agree to the following:

The information presented on this form is accurate, true and correct.
I am acting under authorization of the organization requesting funding from MicroPort CRM.
I confirm that this request is not and will never be tied to the prescription or purchase of MicroPort CRM products or services.

By ticking this box, you accept and agree to Donations & Grants Terms & Conditions *

Electronic Signature: *

Date: *

You must receive a confirmation email to the email address you have indicated above; if you do not, it means that your request has not been successfully submitted to MicroPort CRM.
Please note that due to limited funding, not every qualified request will receive funding.

Approval of a grant or donation request will never be tied to the prescription or purchase of our products. We adhere to all applicable laws, regulations and industry codes of conduct in determining our support for any request.

I hereby consent to the application’s beneficiary personal data being communicated and published by authorities or industry associations. *

Please describe the program, the interest need it will address, and how the funds donation will be used: *

Organization name: *

Organization type: *

501c3 Non-profit (for US only)

Other not for profit

For Profit

Contact Name: *

Contact Email address: *

Contact Address: *

Contact Phone Number: *

Website:

Organization Tax ID:

Organization National Provider Identifier (if applicable):

Please upload W-9 form (for US only):

Program Title: *

Amount Requested: *

Detailed description of the Program/Event: *

Event Location (e.g. country, city): *

Event date(s): *

Venue (e.g. hospital, university, conference center, hotel etc): *

Anticipated number of attendees: *

Target audience/participants:

Is this Program accredited: *

Yes

Additional information or notes, if any:

1. Program/Event’s Budget Breakdown *

2. Program/Event’s Agenda or Description *

3. Official Request Letter from entity requesting the grant (i.e. on letterhead, dated & signed) *

4. Other relevant documentation (i.e. pamphlets, brochures, invitations, etc.)

Please provide the Bank Account details of where the funds should be sent to once/if request is approved [e.g., Bank Name, Account Number, SWIFT/IBAN code, etc.]:

Has your organization received support in the form of a donation or grant from MicroPort CRM in the past?: *

Yes

If any such actual or potential conflict of interest arises you shall immediately inform the Company in writing of such conflict. Please provide the name of your point of contact, if applicable:

Certification

By submitting this application, I acknowledge and agree to the following:

The information presented on this form is accurate, true and correct.
I am acting under authorization of the organization requesting funding from MicroPort CRM.
I confirm that this request is not and will never be tied to the prescription or purchase of MicroPort CRM products or services.

By ticking this box, you accept and agree to Donations & Grants Terms & Conditions *

Electronic Signature: *

Date: *

I hereby consent to the application’s beneficiary personal data being communicated and published by authorities or industry associations. *

Important: As no relationship should exist between MicroPort CRM and the HCP, the demand has to be done by the institution that will receive the fellow without declaring his identity. Any demand coming directly from the HCP has to be rejected.

Please describe the program, duration and location of the fellowship:

Name of the Center: *

Name of the Director of the program responsible for the fellowship: *

Contact Name: *

Contact Email Address: *

Contact Address: *

Contact Phone Number: *

Website:

Organization Tax ID:

Organization National Provider Identifier (if applicable):

Please upload W-9 form (for US only):

Program Title: *

Amount Requested: *

1. Official Request Letter from entity requesting the grant (i.e. on letterhead, dated & signed) *

2. Fellowship’s Budget Breakdown *

3. Other relevant documentation

Has your organization received support in the form of a donation or grant from MicroPort CRM in the past? *

Yes

If any such actual or potential conflict of interest arises you shall immediately inform the Company in writing of such conflict. Please provide the name of your point of contact, if applicable:

Certification

By submitting this application, I acknowledge and agree to the following:

The information presented on this form is accurate, true and correct.
I am acting under authorization of the organization requesting funding from MicroPort CRM.
I confirm that this request is not and will never be tied to the prescription or purchase of MicroPort CRM products or services.

By ticking this box, you accept and agree to Donations & Grants Terms & Conditions *

Electronic Signature: *

Date: *

I hereby consent to the application’s beneficiary personal data being communicated and published by authorities or industry associations. *

Supporting meaningful breakthroughs in medical science

Application for Research, Educational, Charitable Donations and Product Donations from MicroPort CRM

Certification

Certification

Certification

Certification