NICO Education Support Request Form

NICO Education Support Request Form
This form is to be used for requesting equipment, exhibits, or an unrestricted educational grant.
This request is for (select all that apply)

EquipmentExhibitUnrestricted Educational Grant
Event Title
Event Description
Scope of Reach

NationalRegionalLocalInternational
Event Location
Group/Association Name
Event Date(s)
Deadline(s) (if applicable)
Physician Course Director (Name, Email, Phone) (if applicable)
Target Audience (Attending to Resident Ratio)
Grant Amount
Equipment Requested
Exhibit Amount (please attach or indicate each level of support)
Clinical Application (select all that apply)

TumorIntracerebral HemorrhageSpine
Program Type (lab, lecture, grand rounds, etc.)
Potential Number of Attendees (if applicable)
Website URL for Event
CME Accredited (courses only)

YesNo
Unrestricted Educational Grant

YesNo
Event Contact Name
Event Contact Email
Event Contact Phone
Upload Agenda (required)*

Upload a File

Cancelof
Upload Formal Request Letter on Letterhead (required)*

Upload a File

Cancelof
Upload Levels of Support (if applicable)

Upload a File

Cancelof
PLEASE NOTE: We will be unable to review this form without a formal letter of request and event agenda submitted.
Should be Empty: