Group Sponsorship Application

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

Please enter required field - Title
Please enter required field - First Name
Please enter required field - Surname
Please enter required field - Job Title
Incorrect email - Professional Email
Please enter required field - Professional Email
Please enter required field - Professional Address
Please enter required field - Meeting Name
Incorrect date (dd/MM/yy) - Start Date
Please enter required field - Start Date
Incorrect date (dd/MM/yy) - End Date
Please enter required field - End Date
Please enter required field - Objective
Please detail the meeting objective - giving particular attention to how patients will benefit directly and/or how the quality of patient care will be improved as a result of the meeting.
Please enter required field - Award CME Points
Incorrect integer - No of CME Points
Incorrect integer - Expected no of Attendees
Please enter required field - Expected no of Attendees
Please Note that only Physicians, Nurses,Pharmacists and Dentists are considered HCPs
Incorrect floating point number - Total Amount
Incorrect floating point number - Meeting Room Hire
Incorrect floating point number - Refreshments
Incorrect floating point number - Meals
Incorrect floating point number - Other Supports Sought
Drop file here or click to upload
Please enter required field - Supporting Document 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.
Please enter required field - sole sponsor
Is Menarini the sole sponsor? If not, please enter details of other sponsors below.
Please enter required field - supporting documentation
If requested by A.Menarini you will provide invoices and receipts related to this request to verify compliance with the terms of this Agreement.
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.