Organization information Applicant information Description of request Budget Attestation prior to submission Application type * Charitable Contributions Corporate Memberships Corporate Collaborations Organization Name * (Legal entity name, e.g. LLC, Inc. etc.) What type of organization? * For Profit Not-For-Profit Attach W9 * Upload an additional file Attach IRS form * Address 1 * Address 2 City * Country * United States State * Zip Code * Website * Description of the requesting organization and its mission or purpose * Primary Contact First Name * Primary Contact Last Name * Primary Contact Phone * Primary Contact Email * Title of Activity * Description of the activity for which contribution is requested * What will this charitable contribution go towards? * Provide description of Organization, Foundation, Roundtable, Association seeking membership. * Provide brief description of project, including a detailed description of the Program/Project including timeline, agenda, target audience, expected attendance or dissemination, applicable fees and costs and a narrative of the Program, other deliverables as appropriate. * How will Indivior be recognized if funding is provided as a result of this unsolicited request? * Upload supporting documents: flyer, prospectus, etc. * Upload an additional file Amount requested (USD) * Justification for amount requested. * Will there be funding from another organization for this activity? * Yes No If yes, please list: * Is any of the funding confirmed? * Yes No If yes, which one(s)? * Is this organization receiving or planning to receive any other funding or other forms of support for other initiatives from Indivior? * Yes No Describe * Attach an itemized budget * Upload an additional file Confirmation that contribution will not go to any foundation or organization that does not meet the regional definition of a charity, nor to a charitable organization on behalf of, or in the name of, a specific individual in a position to prescribe or recommend any Indivior product. * Yes No Confirmation that the contribution must never be tied in any way to the past, present, or future purchase, prescribing, recommendation, or formulary placement of any Indivior product, or as a reward for any such past behaviour. * Yes No Previous Page Submit Next Page
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