IME Application

INDEPENDENT MEDICAL EDUCATION REQUEST FORM
ACCREDITED AND NON-ACCREDITED EDUCATIONAL ACTIVITIES

Grant requests should be submitted to Covis at least 60 days in advance of the scheduled event and must be on institutional letterhead accompanied by an IRS Form W9, proof of accreditation: (ACCME, ACPE or other) via certificate and a detailed budget and tentative agenda.

Note:  Your application will be reviewed solely based on the scientific merit of the program.  An educational grant will not be determined in a manner that takes into account the volume or value of any business otherwise generated with Covis.  In addition, an educational grant will not affect the purchase, use, recommending or arranging for the use of any Covis product.  Grant funds will not be issued to an individual.  The grant and programs described herein should be for scientific and education purposes only and should not promote Covis or its pharmaceutical products, directly or indirectly.

    This program is accredited; please send certificate(s).This program is non-accredited.


    ACCMEACPEOther







    YesNo


    YesNo


    YesNo


    YesNo

    Please upload:

    1. Summary of request on your institutional letterhead
    2. IRS W9 Form
    3. Detailed Budget
    4. Proof of Accreditation
    5. Tentative Agenda, if available

    Note:  Your application will be reviewed solely based on the scientific merit of the program.  An educational grant will not be determined in a manner that takes into account the volume or value of any business otherwise generated with Covis.  In addition, an educational grant will not affect the purchase, use, recommending or arranging for the use of any Covis product.  Grant funds will not be issued to an individual.  The grant and programs described herein should be for scientific and education purposes only and should not promote Covis or its pharmaceutical products, directly or indirectly.

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