EmailMe Form - Elekta Giving - Grants, Donations, Sponsorships

General information of person submitting the request

Name *

First Last

Phone *

Email *

Is this request being submitting by a physician legally authorized to practice as a Doctor of Medicine in the United States of America? *

Yes

No

If Yes, please provide the following additional information for the U.S. Physician:

Physician name *

First Last

Physician email address *

Physician NPI *

Physician specialty (provider taxonomy code)

Physician license state *

Physician license number *

General information of organization requesting/receiving funds

Organization Name

Email *

Phone *

Tax ID Number (TIN) *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Is this request being submitting on behalf of a “Teaching Hospital” (or an affiliate) located in the United States of America? *

Yes

No

Has Elekta funded the organization this year? *

Yes

No

Has Elekta funded the organization in prior years (if so, provide details)? *

Yes

No

If so, provide details.

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