Sponsorship and Donations Form

To request support from Elekta in the form of Charitable Donations, Educational Grants, Commercial/Conference Sponsorship, or Educational Product Donations please complete the appropriate sections of this Form and attach all required supporting documentation.

Requester Details

Requester Name*

Email*

Requester Phone #

Is this request being submitted at the request of or on behalf of a physician legally authorized to practice as a Doctor of Medicine in the United States of America?*

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Physician Name (if applicable)

Physician Email (if applicable)

Physician NPI (if applicable)

Physician Specialty (Taxonomy Code)

Physician License #

Physician License State

Organization Details

Organization Name*

Tax ID # (TIN)*

Organization Address*

Organization Country*

Is this request being submitting at the request of or on behalf of a “teaching hospital” (or an affiliate) located in the United States of America?*

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Has Elekta funded or provided Educational Products to the organization this year?*

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Please provide details*

Event or Program Details

Funding or Donation Type*

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Do the topics, faculty, attendees and educational materials reflect an objective, legitimate, educational purpose?

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Are the venue and setting conducive to the exchange of educational information?

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Does the agenda reflect the legitimate educational, medical, scientific purpose of the event?

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Is the majority of the event dedicated to recreational activities or free time for the participants?

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Does the event primarily promote the medical or business service of a specific provider or company?

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Will the donation be made to a charitable organization or other non-profit entity with bona fide charitable purpose?

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What is the requesting entity's tax status?

Does the requesting organization have a charitable mission or purpose?

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Will the funds be used only towards charitable purposes?

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Name of Event or Program*

Event or Program Location- City*

Event or Program Location- State*

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Event or Program Location- Country*

Event or Program Website (if applicable) - Paste URL

Date of Event or Desired Product Delivery*

Funding Amount or Equipment Requested*

Subject*

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Specialty*

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Has the event or program been “accredited” for continuing education credit?*

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If so, please list accrediting bodies

Expected audience size or number of program attendees*

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Please describe the purpose of the activity for which the funding or equipment is being requested*

Describe target audience*

Describe how funds or equipment will be used*

Other companies asked for support or educational products*

Will the funds or products be used for expenditures related to the delivery of reimbursable healthcare services to patients?*

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Please describe booth space, advertisement, or demonstration opportunities available in connection with your request (if applicable).

Will Elekta need to supply hardware or software products for demonstration or use during the event?

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Which product is requested?

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If "Other," please specify

Will you require training by Elekta on the requested products?

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Do you require related computer hardware components and/or peripherals from Elekta? If so, please describe

*Please note Elekta may not be able to accommodate requests for associated hardware components

Please specify number of licenses needed and requested configuration

Will the educational program only utilize Elekta products?

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Agreement and Required Attachments

I hereby certify that this funding request is not related, directly or indirectly, to any past, present or future decision to use, purchase or recommend Elekta products or services.*

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I hereby certify that any funds received from Elekta in connection with this request will not be used (in whole or in part) for the delivery of reimbursable healthcare services to patients, including to pay for any related administrative, operational and/or capital costs.*

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REQUIRED DOCUMENTS: The documents listed below MUST BE ATTACHED in order for your request to be considered by the Committee.*

1. Official Program Agenda (including topics, speakers, dates and times) 2. Tax Identification Record or Evidence of Tax Exempt Status 3. (Educational Equipment Donations only) Program Brochure and Accreditation Certificate, if applicable. Additional documents supporting your request may also be uploaded. For example: exhibitor prospectus, invitation letter, etc. Please upload ALL Documents into the area below.

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