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Sponsorship Application Form

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

Healthcare Organization (HCO) Information

Name of Applying HCO: (mohon diisi, nama rumah sakit)

Tax-ID # (if applicable): -

Address: (mohon diisi, alamat nama RS)

Main Phone Number: (mohon diisi, telephone rumah sakit)

Representative of HCO/Primary Contact:

Name: (mohon diisi)


Title: (mohon diisi)

Phone: (mohon diisi)

Email: (mohon diisi)

Bank Account Details:

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),

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Sponsorship Application Form

Countries where HCO operates; attach exhibits if needed:


Indonesia

B. CME Event Information

General information regarding the Event:


Name of Event: KONAS XIII and Annual Meeting PERNEFRI 2017

Date(s) of Event: September 21-23, 2017


Type of Event: Workshop and Symposium
Location of Event (Address): Haris Hotel & Convention Malang,
Jl. A. Yani Utara Riverside Blok C No. 1, Malang, Ja-Tim
Scientific or Medical National scientific program for Hemodialysis
Significance:
Nephrology and Hypertension
Event Characteristics: Regional
National
International

Accreditation Status:
Participants the HCO desires to be sponsored to attend the CME Event and
Sponsorship amount:

Number of proposed .............. (jumlah dokter yang ikut serta)


participants:
Describe professional ...................................... (Nama Dokter yang mengikuti)
specialization(s)/title of each
proposed participant:
Itemized estimated costs per Registration/Participation fee: Rp. 3.000.000,-
participant, as applicable Application fee: _________
(please include the currency) Air transport: approx. _________, (Flight cost est.)
Ground transport: __________
Lodging: Rp. 4.400.000,-
Chek in: 21 Sept 17; Chek out: 24 Sept 2017 (3 nights)
Meals: __________
Total Sponsorship amount
requested:

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Sponsorship Application Form

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:

Phone: 0341-326 167


Email: pitpernefri2017@gmail.com
Contact Person: Dr. Achmad Rifai,SpPD, Tia and Winda
Existing Business Relationship Between HCO and Event Organizer:
Yes No
If answered with Yes, please explain.

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.

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To be determined based on frequency of committees meeting schedule
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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.

...............................................

Place/Date (Tempat dan Tgl) Printed Name, Surname & Function

(Nama, Jabatan sbg representative)

(tanda tangan representative dan Cap RS)

______________________________________

Signature and Stamp of the administrative


Management/authority or signature and stamp of
applying Healthcare Organization

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