Medical Education Grant
Request Form

Requesting Organization Information

Please complete and submit the following application and attach all required documents. Please note that the required lead time for requests is 60 days.

Name of Applicant Organization (Legal Name)

Amount Requested

include Currency Type

Authorized Representative Information

Last Name

First Name

By checking this box I attest that I'm signing this request as a legal representative of this organization.

Street Address

City

State/Province

Zip/Postal Code

Country

Phone

Organization Information

Brief Description of Organization

Is your organization designated as a non-profit or tax-exempt organization by a local tax authority, e.g. the IRS?

If yes, written documentation is required.

Yes

Tax ID #

Program or Event Title

Program or Event Date

Program or Event Venue

Proposed Audience

Anticipated Number of Attendees or Participants

Type of Program or Event

Professional Education

Other

Brief Description of Program or Event

What are the learning objectives of the meeting, and what methods will be used to assess achievement of those objectives? Please include additional supporting documents, e.g. brochures, invitations, program overview/agendas.

Type of Grant

Will Akebia be the sole supporter of this educational activity?

Yes

Name of Accrediting Organization (if applicable)

It is Akebia’s policy not to pay for or support meals, travel, or other expenses for any attendees of any program funded by an educational grant from Akebia. For non-CME programs, if Akebia funds are used to support the costs of faculty expenses, such as honoraria or travel, Akebia will report these transfers of value in accordance with law. The grant recipient will be required to provide Akebia with all information necessary to facilitate such reporting.

Required Documents

The following documents are required to submit a medical education grant request:

Evidence of non-profit or tax-exempt status
U.S. applicants: IRS tax determination letter or Form 990
Non-U.S. applicants: government issued document from the local tax authority confirming non-profit/charity status
Detailed, line-item budget (note: Akebia funds cannot be used to provide meals)
W-9 (for U.S. applicants)
W-8 (for non-U.S. applicants)
Current medical education accreditation certificate, if applicable
Additional supporting documents (e.g. letter of request, detailed program description, needs assessment, program agenda, and evaluation/outcomes plan)

Drop your files here

Send me a copy of my responses

Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Medical Education GrantRequest Form

Requesting Organization Information

Authorized Representative Information

Organization Information

Medical Education Grant
Request Form