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To complete the Lundbeck Grant Online Application you will need the following information and documentation:

Contact Information:

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

Requestor Information:

• Institution or Facility
  • Name
  • Health Industry Number (Optional)
  • Federal Tax ID number or EIN
  • Address
  • Phone
  • Fax (optional)

Activity Information:

• Title
• Objective
• Start Date
• End Date
• Location
• Product
• Disease State
• Requested Amount

Documents to be Attached:

• Provider Accreditation Certification or Status (e.g. ACCME)
• Activity background information (e.g. Brochure, Announcement, Flyer) Optional
• Detailed Line Item Activity Budget
• W-9 Form (i.e. Must be signed and dated within the last year)
• Grant Letter of Agreement (LOA)