Roche Diagnostics & Roche Diabetes Care Funding Request Form

Funding examples: Sponsorships, Memberships, Educational Grants, philanthropic contributions.

If you have any questions concerning this form please email us at laval.businessoperations@roche.com

Please provide a title for your request

Please provide the name of the requestor

Please provide the name of your organization

Please provide requestor's function within the organization

i.e. President, account manager

Please provide an email address for correspondence regarding this request

If you are entering this on behalf of the requestor, please provide your name and email

In which disease area is your initiative primarily focused?

i.e. Cardiac, Women's health, Sequencing

Please select the type of organization

Please describe the target audience for this initiative* If applicable, please describe the number of participants, type of audience (Caregivers, General Public/Consumers, Patients, Biochemists, Nurses, Physicians, etc), geographical scope (national or specific provinces or regions)

Please provide a description and rationale for this initiative.

*Include objective or predicted outcomes, scope and benefit to audience, impact on patients, how Roche’s contribution will be used and/or recognized.

Event start date

Event end date

If event occurs on one day only, please enter the same date as the Start date.

Amount of funding requested from Roche

If multiple levels of sponsorship are available please indicate that the amounts are provided in the documents you have attached.

Please indicate what the funds will be used for more specifically

(e.g. transportation, speaker compensation, catering, etc.)

Please upload applicable supporting documents for this request

i.e. project proposal, draft agenda, sponsorship letter of request, cost breakdown, etc

Drop your files here

Completion of this form does not constitute an agreement of services between Roche and the requestor. Roche's interest and/or decision to invite this proposal for further review does not guarantee funding. Do you understand and agree with the terms stated therein?

By submitting this application you understand and agree that Roche may share information on the outcome of any decision made by Roche in relation to your application within the Roche organization, including with your Roche representative or other field staff. Should Roche agree to provide support for the initiative proposed in this application, you understand that support will be conditional on you and/or your organization agreeing to abide by the terms of a grant, sponsorship, donation, partnership or other agreement with Roche, and your agreement to complete, on Roche's request, a project or event evaluation after the initiative has taken place. Should Roche elect to provide support for the initiative proposed in this application, you agree that information about this initiative may be highlighted in some of Roche corporate communication vehicles and, for the purpose of satisfying global policies or obligations relating to transparency, Roche and its affiliates may collect and publish information relating to this initiative.

By submitting this application you confirm that you have the authority to submit this request and agree to the conditions described below: (a) You confirm that all information and materials contained in this application (“Submission”) are true and accurate, and you confirm that you hold sufficient Intellectual Property Rights (defined below) in the Submission to submit them via this portal, free and clear of any encumbrances. (b) You retain title and full ownership of any Intellectual Property Rights (defined below) in the Submission. However, you irrevocably grant to Roche a limited, non-exclusive, royalty free, worldwide, irrevocable license and right to use the Submission to the extent necessary to administer the processing of your application, and to publicly perform and publicly display the Submission and any materials derived from the Submission. Roche shall have no liability for any Submissions that are lost, intercepted or not received by Roche. Roche assume no liability or responsibility for any error, omission, interruption, deletion, theft, or destruction or unauthorized access to, or alteration of, the Submission. For the avoidance of any doubt, your Submission (and each individual component thereof) shall not be deemed to be confidential.

You consent to receiving email notifications regarding this request and any subsequent emails from Roche or its affiliates that relate to this request or any future grants or sponsorships associated with this initiative.

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