Application Form / Page 5 of 5
1. General Information
Request ID (Bioverativ only)
Application date
Therapeutic area(s) / Hemophilia
Other (Specify):
Please select applicable
sub-type / Corporate Membership
Event / Congress
Exhibits
Program start date
Program end date
Decision needed by date
Organization legal name
Organization EIN
Submitted by
Project title
Amount requested (Please specify currency)
Total program amount (Please specify currency)
Please specify all other sources of funding if any
2. Disclosures
This section is to provide disclosures related to the program for which you are requesting funding or support. Please provide detailed information only if applicable.
Please identify if the program or activities associated with this funding request are to directly support diversity and inclusion efforts
If Yes, please select the diversity and inclusion topic or population targeted / Age
Armed Forces / Veterans
Disability
Gender
LGBT
Racial / Ethnic Minority Groups
Other
Will the funds be used to honor or award a Health Care Professional?
If Yes above, enter name and title of Awardee
Will a public or government official receive an award at this event or through this activity?
Did a public or government official request this funding?
Will any of the funds be used to support or oppose a ballot initiative or for any lobbying activities?
Will any of the funds be used to support or oppose a candidate for elected office?
3. Program Details
This section is to describe the sponsorship for which you are requesting funding or support. Please provide detailed information when applicable and submit any appropriate and necessary supporting document (refer to Section 5).
Brief description
Bioverativ contact name
Primary audience/attendees (Please designate clearly all that apply) / Caregiver; Fellow; General Public; Nurse; Nurse Practitioner; Patients; Pharmacists; General Practitioner MD; Specialist MD; Physician Assistant; Scientist/Researcher; Other (Specify)
Expected number of attendees per type listed above
Geographical focus / Global
National
Regional
Local
Is the Sponsorship or Exhibit opportunity available or made available to other companies?
Sponsorship level and benefits
Is the request related to a Patient or Med Ed Grant?
Have you or will you be requesting support from Bioverativ for the above education activity or event?
Is this request related to a congress, conference, or other scientific or industry meeting? If Yes, please provide details (date, name of event, organizer, etc.)
Are there Bioverativ employees listed as speaker(s) in your agenda? If Yes, please provide full name of employee(s)
Is there a Third Party involved? If Yes, please specify in what capacity (e.g. Education Partner, Logistics Provider) and provide contact information in Section 4
4. Contact Information
Submitter, on behalf of the Organization
First Name
Last Name
Suffix
Title/Position
Organization
Address
Address 2
City
Postal Code
State / Province
Phone Number
Phone Extension
Fax Number
Email Address
Authorized Signatory for the Organization
First Name
Last Name
Suffix
Title/Position
Organization
Address
Address 2
City
Postal Code
State / Province
Phone Number
Phone Extension
Fax Number
Email Address
Third Party (if applicable)
Organization name
Prefix of contact
First Name of contact
Last Name of contact
Suffix of contact
Title/Position of contact
Role/Capacity of contact
Address
Address 2
City
Postal Code
State / Province
Phone Number
Phone Extension
Fax Number
Email Address
5. Additional Information Required
Please provide the appropriate documents as attachment to your application as listed below:
- Full proposal
- Brochure/Flyer/Invitation (Draft copy is acceptable)
- Board Of Directors/Conflict of Interest form
- W-9
- IRS letter of determination, if applicable
- Previous year’s earnings statement (for-profits only) / Form 990 (non-profit only)
- Organization’s total annual budget
- Levels of Sponsorship/Benefits Information
- Any additional document you deem necessary
6. Attestation
Please read these terms and conditions carefully. You must agree to the following terms and conditions before you proceed.
Bioverativ believes that dissemination of scientific and educational information is a worthy undertaking, deserving of support. Bioverativ is committed to carrying out such support in an appropriate manner and in compliance with all applicable laws, rules, regulations, guidelines and standards, including those set by local and regional bodies.
I certify that I am fully authorized to submit this application and provide the information in this application on behalf of the requesting organization and any partner organization(s) and I affirm that all responses and information provided in this application are truthful, accurate and complete.
I attest that the requesting organization, individuals serving or acting as the requesting organization’s directors, trustees and/or principals and I do not appear on any government agency lists of debarred or excluded individuals or entities. Individuals and entities appearing on such lists may be disqualified from receiving educational grants, contributions or sponsorships from Bioverativ.
I certify that my organization does not discriminate on the basis of age, race, sex, national origin, religion, sexual orientation, veteran status or disability.
I understand that I will receive no preference or reward in exchange for past or future prescribing or purchasing Bioverativ products or to induce the prescription or purchase of Bioverativ products. I affirm that I have not been promised any such preference or reward. I agree and affirm that any funds I may receive from Bioverativ are not in any way connected to, or conditioned upon, any past, present or future prescribing, purchasing, or recommending product manufactured or marketed by Bioverativ.
I attest that no Bioverativ employee has solicited a request for Grant support, including Grant requests for Medical Education, Patient Education and other general Grant requests.
I attest that no Bioverativ employee has had any influence or provided any recommendations on the topics, speakers, and/or content for any program(s) associated with this request.
7. Signature
By submitting this application to Bioverativ, I certify, to the best of my knowledge, that the information contained herein is accurate and truthful and that I am authorized to make such statements on behalf of the requesting Organization. / Organization:
Submitter’s Full Name:
Date:
Please submit this form and all appropriate and necessary documents to .
Version 1.0, 1 February 2017