Patient Associations Sponsorship Application

Please complete the form below giving as much detail as possible. Most of the fields are required. You must upload supporting document in PDF format.

Please enter required field - patient association
Please enter required field - address
Please enter required field - contact phone
Incorrect email - contact email
Please enter required field - contact email
Please provide a detailed description of support requested.
Incorrect floating point number - total commitment
Please describe how this support will benefit patients.
Please describe details of any non-monetary support requested and estimated commercial value, if possible.
Please enter required field - sufficient authority
Please enter required field - intended purposes
Please enter required field - other claims
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 - type of support
Drop files here or click to upload
Depending on the nature of your request, we will require backup documentation as set out below to demonstrate our compliance with the IPHA Code of Practice for the Pharmaceutical Industry. If you have any queries regarding what is required, please do not hesitate to contact us.

For a once off project (support for a publication, project or piece of research in which A.Menarini has little or no involvement) we require a detailed description or project plan and cost estimates or quotations justifying the amount requested.

For an organised meeting (support for speaker honoraria, venue costs) we require an agenda, venue details, a copy of proposed invitations or advertisements and cost estimates, clearly indicating proportion to be paid by A.Menarini.

If attending a meeting (contributions towards delegate travel) we require an agenda, venue details, a copy of proposed invitations or advertisements and cost estimates, clearly indicating proportion to be paid by A.Menarini.

Projects of joint interest require a separate contract of support detailing specific responsibilities and costs. If your request is pre-approved, A.Menarini will make contact with you to discuss.

NOTE: Only PDFs may be uploaded.
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.