Checklist

Grant Request Checklist

To complete the Smith & Nephew Biotherapeutic Grant Online Application you will need the following information and documentation.

Please use the Print PDF button at the bottom of this page to print this checklist.

Contact Information

  • Name.
  • Title.
  • Phone.
  • Fax (optional).
  • Email.

Grant Requester Information

If Grant Requester is a Healthcare Provider:

  • Name.
  • State Medical License Number.
  • DEA Number (optional).
  • NPI Number.
  • Address.
  • Phone.
  • Fax (optional).
  • Email.

If Grant Requester is a Healthcare Organization:

  • Name.
  • Health Industry Number (Optional).
  • Employer Identification Number (EIN).
  • Address.
  • Phone.
  • Fax (optional).

Activity Information

  • Title.
  • Objective.
  • Start Date.
  • End Date.
  • Location.
  • Product.
  • Disease State.
  • Therapeutic Area(s).
  • Requested Amount.

Documents (all must be PDF format)

  1. Provider Accreditation Certification or Status (e.g. ACCME).
  2. Detailed Line Item Activity Budget.
  3. W-9 Form (i.e. Must be signed and dated within the last year).
  4. Grant Letter of Agreement (LOA).
  5. Activity background information (e.g. Brochure, Announcement, Flyer).
  6. Grant Letter of Request (LOR) must include the following:
      • Must be on Grant Requestor letterhead.
      • Must be signed.
      • Describes learning objectives.
      • Describes activity or program details.
      • Describes how funding will be used.
      • Includes activity date and venue location.
      • Includes whether activity or program is accredited or non-accredited.
  7. Reconciliation Form must be submitted for all approved grant requests within 90 days of activity.