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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 Pharma 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 LEO Pharma's 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 an asterisk 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 * 
Contact Name (if different from above) 
Contact Title (if different from above) 
Salutation (e.g.: Dr., Mrs., Mr., Ms., Miss.)* 
Business Phone * 
Which Institution/Organization/Clinic do you represent? * 
Name of Organization (Payment made payable to)*: 
Mailing Address* 
E-mail address*  
Organization Website 
Business or Incorporation number, if applicable 
Grants cannot be made payable to individual Healthcare Practitioners.

All funds are paid by EFT. If your request is approved, we will contact you for EFT information.
GST / HST Exempt? * 
GST/HST Registered #* 
QST Registered # 
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 *: 
If this request is for an educational program, will the program be accredited? * 
Is this a new program? * 
Specific purpose for which funds are requested (short description). Include budget details in attachments*: 
Estimated month/year of activity *: 
Event Location Name and Address*: 
Please describe previous funding history with LEO Pharma (if applicable) *: 
List all sponsoring and partnering organizations and describe their role, if applicable (Type “n/a” if not applicable) *: 
Other pharmaceutical companies supporting your project/program? * 
If yes to the above, please specify names of other sponsors:  

Funding Details

Total amount requested (CAD): * 
Total project budget (CAD): 
Please attach any supportive letters or documentation here, including budget details. This is a required field*: