Individual Funding Request

Please complete the form below giving as much detail as possible. Most of the fields are required.

Please note that payments cannot be made to individuals - only to third party suppliers. Applicants cannot be reimbursed for payments already made in association with an educational event.

Please enter required field - Title
Please enter required field - First Name
Please enter required field - Surname
Please enter required field - Medical/scientific professional qualification(s)
Please enter required field - Professional Registration No
Please enter required field - Area of Speciality
Please enter required field - Current Employer
Please enter required field - Job Title
Please enter required field - Professional Address
Incorrect email - Professional Email
Please enter required field - Professional Email
Incorrect date (dd/MM/yy) - Meeting / Course Start Date
Please enter required field - Meeting / Course Start Date
Incorrect date (dd/MM/yy) - Meeting / Course End Date
Please enter required field - Meeting / Course End Date
Please enter required field - Meeting Name
Please enter required field - Objective
Please explain how this support will benefit your patients.
Incorrect floating point number - total funding request amount
Please enter required field - total funding request amount
Incorrect floating point number - Registration Fee
Incorrect floating point number - Travel
Incorrect floating point number - Accommodation
Drop files here or click to upload
Please enter required field - other claims
You are not making a claim from any other party in relation to the support you have requested from A.Menarini in this application form
Please enter required field - sole purpose
Any support given will be used solely and fully for the intended purposes outlined above.
Incorrect floating point number - total amount
In a move towards greater transparency, you are aware that A. Menarini as an IPHA pharmaceutical company, is required to publicly disclose this payment. We are fully committed to transparency with the aim of building better relationships with stakeholders. This disclosure will be made on www.transferofvalue.ie, a platform hosted by IPHA within 6 months of the end of the year in which the transfer takes place. You can contact us to exercise your rights of access, correction or deletion regarding your personal details in relation to ToV by sending an email to ireland@menarini.ie. More information can be found in the transparency section of www.menarini.ie.