Funding Request Form - American Regent

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Funding Request Form

Program Organizer / Grant Requestor

Please enter the contact information for the program organizer.

Main Contact Name

Title

Organization

Street Address

City

State / Province

Zip Code / Postal Code

Phone

(ex. 123-456-7890)

E-Mail Address

Meeting start date / time

(ex. mm/dd/yy)

Meeting end date / time

(ex. mm/dd/yy)

For grants covering multiple meeting dates, please enter the first date and
attach a course brochure or document containing all the meeting dates.

Funding needed by date

(ex. mm/dd/yy)

Meeting location and address

CE Provider / Course Sponsor

Please enter the contact information for the accredited CE provider for the course.

Main Contact Name

Name

Street Address (Where check should be mailed)

City

State / Province

Zip Code / Postal Code

Phone		(ex. 123-456-7890)

E-Mail Address

# of CE credits provided to attendees

Estimated Total Program Cost (Please state in US Dollars only)		$

# of Exhibitors

Funding Requested from American Regent (Please state in US Dollars only)		$

# of Expected Attendees

Attendee Description
(Select the description that most closely matches)

Describe the intended use of the funds

Name of course Faculty/Speakers

Lecture topics and course description of content

How will American Regent be recognized for support

Describe how this program fits within American Regent Guidelines on CE sponsorship:

Additional Comments/Information

Check made payable to

CE Provider/Course Sponsor
Program Organizer/ Grant Requestor

Federal Tax ID#

Please check if you reside outside the US

Check will be made payable to this individual/organization and must also appear on the W-9 form when submitted

Upload Documents

It is preferred if a course outline and or course brochure is attached for review. Draft forms of these documents are acceptable.

Name

Description



File

Submission

Your request for a CE sponsorship funding or grant will be reviewed and considered by American Regent's Grant Committee. Review times may vary however, typical review and response time will be 2-3 weeks. You may check on the status of your request by emailing us at grantapplication@americanregent.com.