Grant Request Form

The following supporting documentation must be submitted with the Grant Request Form:

For Charitable Donation Requests:

• 501(c)(3) Designation Letter
• Statement of Charitable Mission
• Description of Fund-Raising Activity and Levels of Sponsorship
• IRS Form W9

For Educational Sponsorship Requests:

• Overview and agenda of educational program
• Certificate of CME Accreditation and Letter of Agreement under ACCME Guidelines, if applicable
• IRS Form W9  

If the required supporting documentation does not accompany this form, your request will not be considered. The review process may take up to four weeks once the completed grant request packet is received. We cannot guarantee approval of your request.