Funding Support Request

Request Submitted By

Please enter your name as submitter

By submitting this Request for Financial Support, the applicant understands and commits to the following criteria:

Request for funding is to be solely used to support education and the requestor will not use any portion of the amount awarded towards promotion, whether for a product or a business

Should an award be approved and granted by Marinus, the Medical Education Provider [“Provider”] will:

a. sign a Letter of Agreement (LOA) documenting the provisions related to Marinus’ granting financial support

b. independently and objectively control the content of the Program, select the faculty, moderators, venue and target audience

c. disclose to the audience at the time of the Program the source of funding and any relationship between the Program faculty, organizers, or moderators and Marinus

d. bar any promotional activity (including product-related ads or displays) from the immediate area where the Program is conducted (e.g. the Program room and any adjacent hallwaysimmediately outside the program room)

e. conduct a reconciliation of funds after the Program and provide a report to Marinus outlining the categories of spend incurred and how funds granted by Marinus were allocated to individual categories, including whether any funds were not used

f. provide a post-event summary which includes the number of actual participants and a summary of any participant evaluations collected

Grant Request Documents

REQUIRED DOCUMENTS TO BE INCLUDED WITH SUBMISSION:

Letter of request
Program agenda (plus any description or brochure available)
Detailed budget
If an accredited program, proof of accreditation (certificate)

Sponsorship or Corporate Membership Documents

Please attach a letter of request, agenda, prospectus, invitation, or other documents as applicable to the type of request. A description of the membership or sponsorship levels available is required.

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