Medical Education GrantRequest Form

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*

Phone

Email*

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

Other - Event Type*

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*

Select

Will Akebia be the sole supporter of this educational activity?*

Yes

Please list other Supporters*

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)

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