Biogen Idec UK and Ireland Grant and Donation Application Form

Biogen Idec UK and Ireland Grant and Donation Application Form

Grant/Donation Application Please do not amend or remove sections.

(upon completion please sign and return by e-mail with any supporting documentation, alternatively return by post to: Grant and Donation Co-coordinator, Biogen Idec Ltd, Innovation House, 70 Norden Road, Maidenhead, Berkshire, SL6 4AY. For Ireland requests, please return the completed form by email, or return by post to Biogen Idec (Ireland) Ltd, United Drug House, Magna Business Park, Magna Drive, Citywest Road, Dublin 24)

PART I: ORGANISATION

Legal Name of Organisation:______

Briefly describe the nature of your Organisation: ______

______

Healthcare Professional submitting request (PRINT NAME)*:

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Title of Healthcare Professional: ______

Address: ______

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Town/City (include postcode if UK): ______

Telephone: ______Email: ______

x______

Signature of Healthcare Professional from the Organisation* Date:______

* Person should be a representative who is permitted to submit this request on behalf of the organization requesting funding and should be prepared to respond to questions from and provide additional information to the Grant and Donation Committee. Periodic monitoring of programs supported is a part of Biogen Idec’s Compliance Program. Progress Report(s) may be requested by the Grant Committee. Failure to respond to requests for information may impact future funding requests.

PART II: GRANT/DONATION OR EDUCATIONAL PROGRAM DETAILS

Area/services which the funding will support: General Neurology Multiple Sclerosis

Total Amount Requested in (£/€)______

A : GRANT OR DONATION (if your request relates to funding for an educational program, please proceed directly to B: EDUCATIONAL PROGRAM):

Grant for resources and/or medical projects with the sole purpose of contributing to the enhancement of patient care, improvements in the quality of healthcare services which benefit patient care, or advancing medical education/science

Charitable Donation

Other (please specify): ______

B: EDUCATIONAL PROGRAM

Date(s) of Program/Event: ______

Program Title: ______

Program Type:

Patient Education

Professional Education

Medical Education Programs

Fellow/Scholarship Programs

Support for Clinical Practice and Treatment Guidelines

Will this program be accredited? Yes No

 Type of credit: ______

 Number of contact hours: ______

 Accrediting entity and contact information (inc. e-mail address):

______

______

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Anticipated number of attendees: ______

C: DETAILS RELATING TO YOUR FUNDING REQUEST

Please describe your funding request:

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Please explain why the funding needed?

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Please describe how the funding will either advance medical education or science, or contribute to improvements in the quality of healthcare/patient care:

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Address of educational program venue or location of where the grant/donation funding will be utilised:

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Are you planning to request or have you received commitment for support from other companies or organisations? Yes No

Please confirm that, if provided, funds will not result in any personal benefit or financial gain to any individual, except as directed by the mission of your organisation. ______

______

______

If known, describe any involvement or participation of a Biogen Idec employee in your organisation (e.g. employment, consultancy). If known, please describe any involvement of a Biogen Idec employee in this proposal. If this request relates to an educational program, please confirm if any Biogen Idec employee will be involved ______

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PART III: REQUIRED SUPPORTING DOCUMENTATION

Please attach the following to your application:

1. Program/project flyer or brochure (draft is acceptable)

2. Detailed program agenda (topics, speaker names and speaker affiliations)

3. Detailed breakdown of budget costs

4. Completed Payment Information Form (supplied with this form). Should your request be successful, information will be utilised to generate a purchase order as part of our payment process

Grant/Donation Payment Information Form

Grant/Donation Number
(For Office Use only) / Recipient (please ensure these details are the same of those which will be on the invoice)
Name:
Address:
Contact Number:
Description of Grant/Donation
………………………………………………………………………………………………………
Purchase Order Number (internal use only)
Name of Account
Name of Bank
Sort Code: / Account Number
IBAN No:

Signature of Authorised Signatory:

Name and Title of Signatory:

Position of Signatory:

Date: