Financial and In-kind Support for Third Party Educational Programs - Application Request

* Denotes a field that must be completed: Enter "N/A" or "$0" if applicable

Applicant/Entity Details
Entity receiving the financial support
Is the entity owned or controlled by a physician (or family member of a physician) in a position to use or recommend Philips IGT products?
Does the entity employ or have a contractual relationship with a physician (or family member of a physician) in a position to use or recommend Philips IGT products?
Make Check Payable To

Enter the Tax ID (EIN) of Country equivalent (i.e. VAT, CNPJ, etc.) of the Entity to which the check will be sent.
Send Check to...
Applicant Contact Person's Information
Event Details
Event Location
Additional Event Details
(pick as many as applicable) Hold Cntrl down to select multiiple options.
(e.g., golf, tennis, skiing, wine tasting tour)
(Recreational activity between commencement and adjournment of meeting)
(e.g., golf, tennis, skiing, wine tasting tour)
Amount of Funding Requested for:
(Sponsorship or Grant)
Upload Required Documentation:

(Should have the event description on Applicant's Letterhead)

(Topics and times).

Upload Recommended Documentation:

(if a US tax exempt entity)




Certification:
This application for financial support is made for the sole purpose of offsetting the expense of legitimate educational activity, and is not related to or conditional on the inception or continuation of any business relationship with Philips IGT or any of its employees or affiliates.