Reata Pharmaceuticals Inc. - Grant Request Form

Before completing this grant request form, please make sure you have read and understand the requirements for submitting an application and the types of programs that may be considered for funding.

1. Are you requesting a grant for accredited independent medical education? *

YesNo

2. Organization Requesting Grant *

3. Contact Information

First Name*

Last Name*

Email*

Phone Number*

4. Amount Requested *

5. Grant Utilization

Program/Event Title*

Program/Event Date(s)

Program/Event Location/Venue *

Program/Event Description *

Please attach the following required documentation: *

Attach additional supporting documentation if appropriate: 

Proposed itimized budget for program/event
Draft agenda
Objectives
Other supporting materials

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6. Additional Program/Event/Congress Information (if not applicable, continue to 7)

Anticipated Attendance (i.e., Specialists, Nurses, Coordinators, etc.)

Number of Attendees

Other Grantors/Potential Grantors

Accreditation Information, if applicable

Accrediting Body

Credit Category and Hours

7. Requested Decision Date, if any *

Please allow a minimum of 60 business days

8. The following information is required to process all payments and may be submitted with this Form or separately, upon notification that a Request has been approved

Please attach the following documentation:

Completed W-9 Form (Tax ID)
Automated Clearing House (ACH) Instructions (include bank name, account number, and routing number)
For Accredited CME: Accreditation Statement

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Automated Clearing House (ACH) Instructions (include bank name, account number, and routing number)

For Accredited CME: Accreditation Statement

9. Acknowledgements and Signature

Reata is committed to compliance with all applicable federal and state pharmaceutical industry laws, regulations, and guidelines. By submitting this application, Requestor represents their commitment to act in accordance with the above in the event that the request is approved.
Submission of this Grant Request Form and supporting documentation does not constitute nor represent a funding commitment by Reata. Funding decision is subject to approval by Reata’s internal review committee, which may approve or decline a request in its sole and absolute discretion. Reata reserves the right to award less than the amount requested based on program merit, business objectives, and budgetary constraints. If, for any reason, the program or event does not occur, or the awarded funds prove to be in excess of the estimated program costs, the unused portion of the grant shall be returned to Reata. Reata will not provide supplemental grants retrospectively to cover program expense overages.
Requestor represents and warrants that this request is unrelated to the future purchase, use or recommendation of Reata products. In addition, Requestor acknowledges that their organization will maintain control over the program/event at all times and that Reata may not influence the content, or selection of speakers, attendees, or individual recipients of fellowships or scholarships, where applicable. I hereby further certify that the information provided in this request form is complete and correct, and that I have the authority to submit this request on behalf of the organization requesting support.

e - Signature *

Date*

Title *

This completed Grants Request Form and required documentation will be sent to Grants@ReataPharma.com. This form is intended for U.S. use only.