Grant Request Form

 

Here are a few things to consider when submitting your Grant request:

A grant is a voluntary award of funds by LEO to a worthy and eligible recipient.  The recipient must have submitted an unsolicited request to support bona fide independent educational programs, activities, or materials which benefit HCPs, patients or other public health initiatives.  This also includes research grants for non-Investigator Initiated Studies with a focus on LEOs therapeutic areas or disease states of interest, including  Dermatology and Thrombosis. 

Worthy and eligible recipients of a Grant include institutions, professional or scientific organizations, hospitals, academic medical centers, schools of nursing or pharmacy, professional societies and associations, and other entities with a mission related to healthcare professional education and/or healthcare improvement or patient advocacy associations.

Please note that we cannot award grants directly to individual healthcare practitioners.


All fields marked with  must be completed in order to process your request. We aim to notify applicants within 90 days of receipt.

Please note Grant funding can be awarded to groups or organizations only, not individuals.

Applicant Organization Details

Who is your LEO Pharma Contact Person? * 
Requestor's Name * 
Requestor's Title * 
Which Institution/Organization/Clinic do you represent? * 
Should your Grant request be approved for funding, cheque made payable to:
Name *: 
All funds are paid by EFT. If your G/D/S request is approved, we will contact you for EFT information.
Full Address * 
Business or Incorporation number, if applicable 
Grants cannot be made payable to individual Healthcare Practitioners.
If you prefer to receive funding through Electronic Fund Transfer (EFT), please check here *:
 
GST / HST Exempt? * 
GST / HST # * 
QST # 
Prefix 
Contact Name 
Contact Title 
Address 1 * 
Address 2 
City * 
Province * 
Postal Code * 
Country * 
E-mail address * 
Website 
Phone Number * 
Ext # 
Please provide your organization’s principal purpose and services *: 
Government employee means involvement in formulary or reimbursement decisions, participation in guidelines committees or practice protocol development or Hospital P&T committees.
Are any members of the board of your organization government employees? * 
If yes, please list name(s): 

Project/Program Information

Project/Program Title *: 
Specific purpose for which funds are requested (short description) *: 
Estimated month/year of activity *: 
Please describe previous funding history with LEO (if applicable) *: 
List all sponsoring and partnering organizations and describe their role, if applicable (Type “n/a” if not applicable) *: 
Other sponsoring industry partner(s) (Type “n/a” if not applicable) *: 
Other partner(s) (Type “n/a” if not applicable) *: 
If this request is for an educational program, will the program be accredited? * 
Is this a new program? * 

Funding Details

Total amount requested (CAD): * 
Total project budget (CAD): 
Agreement contract made out to (individual’s name) *: 
Please attach any supportive letters or documentation here: