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Diabetes Care-Related Charitable Support Application
First Name
*
Last Name
*
Contact Email
*
Contact Phone
*
(xxx) xxx-xxxx
Organization Name
*
Organization Taxpayer ID (EID)
*
xx-xxxxxxx
Organization Most Recent W-9 *
Organization Most Recent W-9
*
Files must be less than
5 MB
.
Allowed file types:
pdf
.
Is your organization recognized by the IRS as a tax exempt, public charity under sections 501(c)3 and 501(c)6 of the Internal Revenue Code?
*
Yes
No
Is your organization a US governmental organization (e.g., public school, public college or university, public hospital or federally recognized Indian tribal government)?
Yes
No
Is your organization located in the United States?
*
Yes
No
Will the event/request take place in the United States?
*
Yes
No
Is the event related to the diabetes disease state?
*
Yes
No
Is your organization owned wholly or in part by a physician or a group or physicians, including group practices, privately owned physician offices, or charitable foundations of small group practices?
*
Yes
No
Is your organization a political or sectarian organization?
*
Yes
No
Will the funding be used for one of the following: Advertising, Alumni Drives, Capital Funding, Continuing Medical Education, Infrastructure, Memberships, Professional Sporting Events or Athletes, Religious Causes, Scholarships, or A Specific Individual?
*
Yes
No
Will Roche be the sole supporter of the event or program?
*
Yes
No
Request Title
*
Request Address
Street Address Line 1
*
Street Address Line 2
City
*
Zip
*
Fulfillment Date for Request
*
Month
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
Audience Type for Request
*
- Select -
Healthcare Professionals
Media / PR
Patients
Audience Size for Request
*
Request Type
*
- Select -
Monetary
Product Donation
Request Amount ($)
*
You may request up to five product types.
Request Products
- None -
Accu-Chek Guide Me meter
Accu-Chek Guide meter
Accu-Chek Aviva meter
Accu-Chek Guide test strips
Accu-Chek Aviva Plus test strips
Accu-Chek SmartView test strips
Accu-Chek FastClix lancing device
Accu-Chek Softclix lancing device
Accu-Chek FastClix lancets
Accu-Chek Softclix lancets
Quantity
Request Products 2
- None -
Accu-Chek Guide Me meter
Accu-Chek Guide meter
Accu-Chek Aviva meter
Accu-Chek Guide test strips
Accu-Chek Aviva Plus test strips
Accu-Chek SmartView test strips
Accu-Chek FastClix lancing device
Accu-Chek Softclix lancing device
Accu-Chek FastClix lancets
Accu-Chek Softclix lancets
Quantity 2
Request Products 3
- None -
Accu-Chek Guide Me meter
Accu-Chek Guide meter
Accu-Chek Aviva meter
Accu-Chek Guide test strips
Accu-Chek Aviva Plus test strips
Accu-Chek SmartView test strips
Accu-Chek FastClix lancing device
Accu-Chek Softclix lancing device
Accu-Chek FastClix lancets
Accu-Chek Softclix lancets
Quantity 3
Request Products 4
- None -
Accu-Chek Guide Me meter
Accu-Chek Guide meter
Accu-Chek Aviva meter
Accu-Chek Guide test strips
Accu-Chek Aviva Plus test strips
Accu-Chek SmartView test strips
Accu-Chek FastClix lancing device
Accu-Chek Softclix lancing device
Accu-Chek FastClix lancets
Accu-Chek Softclix lancets
Quantity 4
Request Products 5
- None -
Accu-Chek Guide Me meter
Accu-Chek Guide meter
Accu-Chek Aviva meter
Accu-Chek Guide test strips
Accu-Chek Aviva Plus test strips
Accu-Chek SmartView test strips
Accu-Chek FastClix lancing device
Accu-Chek Softclix lancing device
Accu-Chek FastClix lancets
Accu-Chek Softclix lancets
Quantity 5
Event Details (Flyer, Letter, Etc.) *
Event Details (Flyer, Letter, Etc.)
*
Files must be less than
5 MB
.
Allowed file types:
pdf
.
Request Description
*
Leave this field blank