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Sponsorship to International Conference or Congress Request Form

 

Here are a few things to consider when submitting your Sponsorship to an International Conference/Congress request:

A sponsorship is a voluntary award of funds by LEO to an unsolicited request made by a Healthcare Practitioner to attend a bona fide international conference or congress with focus on Dermatology or Thrombosis to help ensure Canadian stakeholders are educated and informed of developments in health research, health sciences and clinical practice for their profession at an international level to improve health care for Canadian patients. 

The international conference or congress must have a clearly defined educational or scientific purpose and is defined as accredited, endorsed, or sponsored by academic societies, and professional associations or organizations.  Sponsorship of attendees to a Canadian Third-Party Educational or Professional Conference or Congress is prohibited.

The recipient of a Sponsorship fund is required to share the knowledge gained within 6 months of the event as follows:

The submission of a report or paper to LEO Pharma Canada or

Through a written report to the specialty society/academic institution or

A verbal presentation to HCPs

Such papers and/or presentations must include a statement by the author/presenter acknowledging that they received financial support from LEO Pharma Canada to attend the international event.

The Requestor must advise whether or not funding support has been requested from more than one source to attend the same event. Funding from all sources is not to exceed total costs that are anticipated for supported items.

Please note that we cannot award sponsorships directly to a healthcare organization.

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 Sponsorship funding can be awarded to individuals only, not groups or organizations. Please complete one form per individual.

Applicant Organization Details

Who is your LEO Pharma Contact Person? * 
Requestor’s name *: 
Requestor’s title *: 
Institution/Organization/Clinic name *: 
Should your Sponsorship request be approved for funding, cheque made payable to:
Name * 
Full Address * 
Sponsorships cannot be made payable to Healthcare Organizations.
All funds are paid by EFT. If your G/D/S request is approved, we will contact you for EFT information.
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 # 
Government employee means involvement in formulary or reimbursement decisions, participation in guidelines committees or practice protocol development or Hospital P&T committees.
Are you a government employee? * 
If yes, please specify: 

Conference / Congress Information

Conference / Congress Title *: 
Location (must be outside of Canada) *: 
Specific purpose for which funds are requested (short description): 
Event start date *: 
Event end date *: 
Please describe previous sponsorship history with LEO (if applicable) *: 
Will you be requesting funding from other industry partners? * 
Has support been requested from more than one company to attend this event? 
Please briefly describe how you will share the information learned at the conference / congress upon return to Canada *: 

Funding Details

Total amount requested (CAD) *: 
Total project budget *: 
General overview of the budget. (i.e. approximately how much of the funding will be budgeted towards accommodation, toward meals, towards registration, etc.) * 

If requesting Sponsorship to attend a Conference or Congress:

Please provide specifics of the educational program(s) to be delivered upon return to Canada *: 
Agreement contract made out to (individual’s name) *: 
Please attach any supportive letters or documentation here: