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This form is required for all requests by Healthcare Organizations for financial support from
Fresenius Medical Care for continuous medical education (CME) events and activities that
further professional development, patient education or policy initiatives. Please note that only
fully completed forms submitted by the Applicant will be processed. For any answer requiring
more space than is given in this form, please attach complete answers on separate sheets of
paper.
A. General Information Regarding Applicant
Account Holder: NA as all costs are paid for by Fresenius Medical Care directly
to vendors
Account Number: NA as all costs are paid for by Fresenius Medical Care directly
to vendors
Bank Code: NA as all costs are paid for by Fresenius Medical Care directly
to vendors
Name of Bank: NA as all costs are paid for by Fresenius Medical Care directly
to vendors
HCO Status: Public Healthcare Sector Private Healthcare Sector
Provide a brief description of the HCOs background, overall mission, and objective; a brochure
is acceptable.
(Deskripsikan tentang RS, mohon diisi),
Accreditation Status:
Participants the HCO desires to be sponsored to attend the CME Event and
Sponsorship amount:
Event Organizer:
Name: PB PERNEFRI
Address: RSUD dr. Saiful Anwar,
Jl. Jaksa Agung Suprapto No. 2, Malang
Phone: 0341-326 167
Email: pitpernefri2017@gmail.com
Contact within Event Organization:
Notice to Applicant:
1. Please provide the Sponsorship Application at least X1 weeks prior to the planned event
date.
2. Please attach and reference any information that supports your application, such as a
brochure describing the event.
3. All Sponsorship requests will be reviewed and considered in accordance with FMCs
Sponsorship Policy prior to any funding.
4. FMC will consider Sponsorship Applications from Healthcare Organizations only.
Applications provided by an individual will be returned.
5. Expenses eligible for Sponsorship are limited to the event application fee, as well as
reasonable travel, meals, and accommodation costs.
6. If this request is approved, receipts for all expenses incurred, and proof of attendance at
the event, are to be provided to FMC within thirty (30 days) after conclusion of the event.
7. If the Applicant does not comply with all requirements of the Sponsorship Policy, the
Applicant may be ineligible to receive future funding. In addition, the organization will
be required to return to FMC any sponsorship funding that is not supported by a receipt.
8. FMC reserves the right to reject any application.
1
To be determined based on frequency of committees meeting schedule
DRAFT_ Strictly Confidential Page 3 of 4
Sponsorship Application Form
I confirm that I am authorized by (mohon diisi, nama RS) to request this sponsorship on the
organizations behalf, and that all information provided on this application is accurate and
complete. I understand that the withholding of information or provision of false information
will result in a rejection of the application. I confirm that (i) the requested sponsorship is not
contingent upon, or intended to influence or reward, any past, current, or future FMC business
transaction, opportunity or government approval; (ii) all proposed attendees will have a
legitimate professional interest in the subject of the CME Event for which the sponsorship is
sought; (iii) the attendees will be selected by the organization based on his or her
qualifications and expertise, and not as an inducement or reward for his or her past, current, or
future purchase or referral of FMC business; (iv) the requested funding will be used solely for
the purposes stated herein; and (v) the organization will return to FMC any sponsorship
funding that is not supported by a receipt submitted to FMC within thirty (30) days after the
conclusion of the CME Event.
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