Fujifilm Endoscopy Grant Request Acknowledgement

Grant Request
FUJIFILM Healthcare Americas Corporation (Fujifilm) may provide financial support to professional education opportunities related to Endoscopy, Pulmonology, and/or Endosurgery by providing funding to accredited hands-on training programs supported by national medical societies and/or academic medical institutions.

As you fill out the required Educational Grant request application below for consideration, note that Exhibit, Educational Grant, and In-Kind Equipment applications need to be submitted, reviewed, and approved as separate requests. In addition, for the purpose of these applications, all educational programs must take place in the United States of America.

At Fujifilm, we appreciate your application. We receive many worthwhile requests, and unfortunately, due to budget limitations, we are unable to fund them all. Please note that past funding of a Grant does not guarantee funding approval of your current Grant application. Applications may also be approved at an amount less than the requested amount. Additional questions or information beyond this form may also be required to process your application.

Do not assume that an application has been approved because it has been submitted. Requestors will receive an email notification of approval or denial of their application.

NOTE: Unrestricted grant requests are not accepted.
* Required Fields & Required Documents
Contact Information
Name*

First NameLast Name
Title*
Company*
Email*
example@example.com
Phone Number*
Grant Information
Event Date (If Applicable)

MonthDayYear
Date
Name of Event/Grant Request*
Grant Amount Requesting*
What is this grant request for? *

Educational Grant
Is this grant for an accredited CME program or a non-accredited CME program?*

Accredited CMENon-Accredited CME
* REQUIRED DOCUMENTS INCLUDES SUBMISSION OF AN LOA (Letter of Agreement) or Commercial Support Agreement
If this grant is for an accredited CME program, who is the accreditor?*

ACCME AccreditedOther
Description of event (including goals and objectives)*
Number of expected attendees *
Payment Information (How to Make the Check Payable)*
Are you requesting equipment in addition to a grant? (If Yes, please complete the in-kind equipment request form.)*

YesNo
In-Kind Equipment Request
Is this equipment for a CME or Non-CME program?

YesNo
Please include description of products and quantities. Example: (1) CORE GI Tower, (1) EG-760R – Standard Gastroscope
Duration of equipment loan? (Ex: 3 days, 1 month, 90 days)
In-Kind Equipment Request Type
What is this in-kind equipment request for, please check based on the following:

Hands-On Course or LabResearch Clinical StudyLive Case Procedures
Course Focus / Type of Stations

Core GIInterventional GIESDThird Space EndoscopyPulmonaryEndosurgery/MISOther
Location Type*

Convention CenterHotelHospitalOther
Is VET equipment being requested? (i.e. If this is for hands-on, will porcine/pig models be used)

YesNo
Is this equipment being used for human patients?

YesNo
Shipping Information
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Contact
Shipping Contact

First NameLast Name
Shipping Email
example@example.com
Shipping Phone Number
Equipment Delivery Date

MonthDayYear
Date
Equipment Return Date

MonthDayYear
Date
Special Shipping Logistics (Select All That Apply)

Loading DockLift GateStorage for crates/equipmentShipping Hours
Hotel Contact
Hotel Contact Name

First NameLast Name
Hotel Contact Email
example@example.com
Hotel Phone Number
Live Cases
Facility or Hospital Contact

First NameLast Name
Facility or Hospital Email
example@example.com
Facility or Hospital Phone Number
Is a no-charge PO required?

YesNo
Upload Documents
Browse Files
Upload files from your device to the form. Cancelof
Grant Form Requirements:

The following documents are REQUIRED in your submission. Failure to upload these documents will result in a delayed approval or rejection.
1. A completed FUJIFILM Healthcare Americas Corporation Grant Application using our submission form.
1. A comprehensive program description or agenda, including grant and program overview, faculty and curriculum focus, clinical schedule, and research components, etc.
1. A letter of request & a letter agreement on your institution's letterhead and signed by the director of the program.
1. An itemized budget for the program’s expenses and amount of support requested from FUJIFILM Healthcare Americas Corporation.
1. Copy of the Certificate of Accreditation if this is for a CME program.
1. Payment Information (How to make the check payable)
1. Completed W-9 form
In-Kind Equipment Form Requirements:
1. A completed FUJIFILM Healthcare Americas Corporation In-Kind Equipment Request Application using our submission form.
  Please note: Apply at least 90 days prior to event start date.
  - Course/Requestor Contact – (First/Last Name, Email, Phone)
  - Shipping Information / Contact – Including any specialty information we should know (lift gate information, dock info, etc)
  - Duration of Equipment Loan (Start/Delivery Date & End/Return Date)
  - CME or Non-CME Request Type
2. A letter of agreement / letter of request on the program or provider’s letterhead that includes:
  - Equipment Request (description of course or in-kind equipment needs), (ex: quantity and type of equipment needed.)
3. Program agenda, or brochure.
4. Completed W-9 form
Should be Empty:

Grant Request

Contact Information

Grant Information

In-Kind Equipment Request

In-Kind Equipment Request Type

Shipping Information

Shipping Contact

Hotel Contact

Live Cases

Upload Documents