Journal Clubs and Rounds application form

Personal data about you collected by Abbvie Corporation, ("AbbVie"), as part of your grant or donation request is subject to our Privacy Notice which describes how AbbVie processes your personal data and your data privacy rights.

Name of the requesting entity

required

Name of requesting individual

required

E-mail of the requesting individual

required

Street

required

City, Province

required

Postal code

required

Telephone

required

Legal authorized representative to sign contract

Legal authorized representative name

required

Legal authorized representative title

required

Legal authorized representative e-mail

required

Registration Number

required

Briefly outline your funding request (75 to 200 characters)

of 200 characters available

required

$ Amount requested (CAD)

required

The amount should be inclusive of all fees related to the event, as per the detailed budget breakdown.

If your request is less than 45 days away, please e-mail [email protected] to obtain a PDF version of this application form, as you will not be able to submit your application through the Web site.

Project start date

required

Project end date

required

Other therapeutic area

required

Is the venue a hospital, a clinic or an academic institution? required YES NO

Can AbbVie employees attend a Journal Club or Round as an observer? required YES NO

AbbVie representative name (if known):

Have funds been solicited from other sources? required YES NO

The application hereby confirms that any of its managing members, do not have any actual, or potential conflict of interest with AbbVie or Allergan (required)

Please also attach your dated letter of request on your organizations letterhead,including a detailed budget breakdown, with the completed application form.

ATTACHMENTS Allowed File Types : PDF, Word, PowerPoint, Excel

*As part of our ongoing commitment to maintain a high level of integrity of our grants and donations program, we review our selection criteria on an ongoing basis.