Fujifilm Endoscopy In-Kind Equipment Request Acknowledgement

In-Kind Equipment Request
FUJIFILM Healthcare Americas Corporation (Fujifilm) may supply in-kind equipment for professional education purposes to accredited hands-on training programs and labs related to Endoscopy, Pulmonology, and/or Endosurgery supported by national medical societies and/or academic medical institutions.

As you fill out the required In-Kind Equipment 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 fulfill them all. Please note that past support of an In-Kind Equipment request does not guarantee approval of your current 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.
* Required Field
Contact Information
Name*

First NameLast Name
Title*
Company*
Email*
example@example.com
Phone Number*
Name of Event*
Description of event (including goals and objectives)*
Number of expected attendees *
Equipment Information
Is this grant for an accredited CME program or a non-accredited CME program?*

Accredited CMENon-Accredited CME
If this grant is for an accredited CME program, who is the accreditor?*

ACCME AccreditedOther
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 ProceduresCompatibility Testing
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 Contact Phone Number
Live Cases
Facility or Hospital Contact

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

YesNo
Upload Documents
Browse Files
Upload files from your device to the form. Cancelof
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
1. 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.)
1. Program agenda, or brochure.
1. Completed W-9 form.
Should be Empty:

In-Kind Equipment Request

Contact Information

Equipment Information

In-Kind Equipment Request Type

Shipping Information

Shipping Contact

Hotel Contact

Live Cases

Upload Documents