MEDA Grant Application Form
Instructions Complete all fields, then submit this application via the button below. Grant requests must be submitted at least 12 weeks in advance of the activity start date. To avoid delays in the evaluation process, complete, accurate and detailed information is required. Applications with insufficient information will either be denied or will require resubmission. The MEDA Grants Office will send you a confirmation via email containing your Grant Application Number upon receipt of your grant request. This application is meant for grants requests in support of bona fide educational activities that are CME/CE or Non CME in nature. This grant request process is not intended for clinical research grants or charitable contributions. You may direct any questions to the Meda Grants Office at 732-564-2565 or grants@medapharma.us.
Grant Requestor
Organization Name:
Requestor Name:
Requestor Address:
Federal Tax ID:
Name of Contact at Requesting Organization:
Contact Phone Number:
Contact Fax Number:
Contact Email:
Program Information
Start Date:        End Date:
Venue/Location:
Institutional Affiliations (if applicable):
Accredited Program         Non-Accredited Program
Accreditor:
Accreditation Type:
Number of Credits:
Educational Needs Assessment:
Title:
Agenda:
Learning Objectives:
Instructional Methods/Vehicles (e.g., live, print, enduring, etc.):
Evaluation or Outcomes Plan:
Speaker & Attendees
Speaker Qualifications (names not required):
Target Audience: NP    PA    PCP    Allergist                          ENT     Pain Specialist    Other
Anticipated Number of Attendees:
Budget Information
Total amount of grant money requested:
Budget breakdown demonstrating how the grant money will be spent. Please be as detailed as possible, including (by way of example) allocation to areas such as: Content development Development and printing Recruitment materials Program materials Resources Faculty travel and miscellaneous Faculty Honoraria Program management Meals affiliated with education event Are there multiple sponsors? Yes    No    If yes, how many?
You may attach one or more files to the application that includes any relevant supporting documentation. You may attach as many as five (5) files. The following formats are accepted; .txt, .rtf, .doc, .docx, .xls, .xlsx, and .pdf.