NICO Education Support Request Form

NICO Education Support Request Form
This form is to be used for requesting equipment, exhibits, or an unrestricted educational grant.
This request is for (select all that apply)

Equipment Exhibit Unrestricted Educational Grant
Event Title
Event Description
Scope of Reach

National Regional Local International
Event Location
Group/Association Name
Event Date(s)
Deadline(s) (if applicable)
Physician Course Director (Name, Email, Phone) (if applicable)
Target Audience (Attending to Resident Ratio)
Grant Amount
Equipment Requested
Exhibit Amount (please attach or indicate each level of support)
Clinical Application (select all that apply)

Tumor Intracerebral Hemorrhage Spine
Program Type (lab, lecture, grand rounds, etc.)
Potential Number of Attendees (if applicable)
Website URL for Event
CME Accredited (courses only)

Yes No
Unrestricted Educational Grant

Yes No
Event Contact Name
Event Contact Email
Event Contact Phone
Upload Agenda (required) *
Upload Formal Request Letter on Letterhead (required) *
Upload Levels of Support (if applicable)
PLEASE NOTE: We will be unable to review this form without a formal letter of request and event agenda submitted.
Should be Empty: