Please enter required field - Title
Please enter required field - First Name
Please enter required field - Surname
Please enter required field - Job Title
Please enter required field - Professional Address
Incorrect email - Professional Email
Please enter required field - Professional Email
Please enter required field - Phone
Please enter required field - Organisation
Please enter required field - Requesting Support For
Please enter required field - Details of Request
Please enter required field - Type of Funding
Incorrect floating point number - Funding Amount
Please enter required field - Funding Amount
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
Please enter required field - influence
I confirm that the patient association / HCO (including its directors) has no real or perceived influence which could be considered likely to influence the activities of MENARINI.

A real or perceived influence can emerge from the following situations:
  • Employee of a Health Agency, a Public Official or an expert for a health authority.
  • Member of a Commission, an Advisory Committee or any legal structure or entity that develops recommendations for health authorities or agencies or for a commercial partner making purchasing decisions for hospitals or other public or private establishments or being responsible for allocating budget allocations or expenditures.
  • Position having an influence on the interests of MENARINI, including financial interests.
  • Any relationship, commitment or financial interest that may compromise or appear to compromise your relationship with MENARINI.
  • Having a close family member with the influences listed above.