Grant Application Form

Please enter the requested information in the form below and attach any additional documentation you deem appropriate. Or, you may print out the document, fill out the information, attach your documents and email to educationalgrants@indivior.com

Requests should be submitted at least 60 days prior to the scheduled program or activity.  The Grant panel meets the last Thursday of each month and the review window closes on the prior Thursday. Your request will be reviewed and you will be notified of the Grant Review Board as soon as we are able after each meeting.

The application must be complete and all documentation requested must be provided or your grant will not be considered.

GRANT DETAILS/REQUIREMENTS: For use in US/Canada only. All others contact the regional office for information.

All information is required.

Event Name:

CME Eligible:
YesNo

Event Date (mm/dd/yyyy):

Event Location:

Requested Amount of Grant:
$

Total Cost of Program:
$

Please include your formal request on official letterhead. (attach your request in PDF or Word):

Event Description including program agenda:

Total number of attendees:

Speaker Information (Attach list of proposed speakers in PDF or Word):

Budget (attach a fully itemized and detailed budget in PDF or Word).

Are you receiving funding from any other organization? YesNo
If yes, please list:

Are you a government sponsored organization?
YesNo

If Yes, Does this fit with the rules of your organization?
YesNo

Explain:


GRANT RECIPIENT:

Organization Name:

What type of organization?
ProfitNot-For-Profit
(W-9 or Proof of tax exemption is required. You may upload your PDF or Word Doc here)

Street Address:

City:

State:

Zip:

Website:

Contact Name:

Contact Phone (xxx-xxx-xxxx):

Contact Email:

Please note that a reconciliation may be required after your event occurs. If your grant is selected, you will be notified in writing.

Requested by (Signature):

By typing in your name above and checking the acceptance box, this will represent your signature.

Title:

Company:

Date:

We may provide your personal information to companies that provide services to help us with our business activities such as shipping your order or offering customer service. These companies are authorized to use your personal information only as necessary to provide these services to us.