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SAMPLE
RE: Request for Review and
Approval of Non-Profit Educational Activity
TO: XYZ Research &
Education Foundation
DATE: ___________________________
Request submitted by:
_______________________________________________________
Name of Donor:
_____________________________________________________________
Amount: _____________________________
Funds will be used to support the following education
actgivity:
____ Sponsor staff or patient education and training
activity
____ Attend education and training activity
Name of person who will participate in the activity
if different from the person submitting this request: ________________________________________________________________
____Other___________________________________________________________________
Describe the education and training activity and explain
how it will benefit VA.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Attach supporting documentation (program brochure,
course description, etc.).
I certify that this education and training activity
supports the VA's education and training mission and that this activity
is within the scope of the donor's intent.
Signature: ________________________________________
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____ Approved ____ Disapproved
By __________________________________________ Date____________________
Executive Director, XYZ
Referred to Education and Training
Subcommittee Date____________________ |
