Roche Support Request Form

Applying for support

In order to apply for support, healthcare organisations and patient organisations must complete the form below.  Below is a guide to help make the process smoother. Please note that failure to complete this form fully with all necessary information will delay the assessment of your request.

Guidance for filling out the form:

  • Fill out all of the fields. 
  • The bank account details you provide should be for the relevant healthcare institution. If approved, support from Roche is always transferred to the healthcare organisation, not to the individual healthcare professional. 
  • For contractual reasons, Roche typically requires the head of department and the finance department to sign off on the support contract. If you are from a patient organisation, the CEO and the Head of Finance may be required to sign the contract. 
  • Grants, Sponsorships and Donations will only be provided to Healthcare Organisations or Healthcare-Related Entities for the purpose of supporting healthcare or research 
  • All support is given to campaigns, initiatives and events that benefit patients and/or public health. Ensure that you highlight how your request does this. 

Roche's Irish business have strict processes in place to ensure that all Grants, Sponsorships and Donations are provided in accordance with the Roche Pharma Directive on Grants, Sponsorships and Donations and respective legal requirements. Roche 

Roche Support Request Form

Applicant Details
Note: The Applicant is the institution, rather than the individual employed by the institution submitting the request
All requests for support received can expect a decision by the end of the following month (e.g. if a request is received on 15th February, a response will be communicated by 31st March)

Institution (Hospital/Practice/Organisation) Details

Contact Person Details

Support Request Details (CME, Congress, Healthcare Projects or Programme)

30 characters left

Funding and Payment Details

Funding can only be transferred into an account of the institution submitting the request for support

By submitting this request, I agree that if my request is approved, I will provide evidence that the support was used for that stated purpose.