Gilead UK & Ireland Community Grants Programme
Application form: core funding
Please complete electronically and return to us by email.
Closing date for applications is 10 April 2015.
Gilead Sciences Ltd provides financial grants to individual patient organisations or groups of patient
organisations (a registered charitable organisation or a recognised healthcare organisation where
some funding comes from the NHS) in the UK and Ireland in the area of blood borne viruses, the
most prevalent of which are HIV, hepatitis B and hepatitis C.
Our Community Grants Programme is administered in a manner that ensures transparency in process
and compliance to the ABPI Code of Practice for the Pharmaceutical Industry whilst maximising the
benefit for patients and the wider community.
Gilead Sciences is committed to compliance with the ABPI Code of Practice for the Pharmaceutical
Industry at all times and will not provide funding for projects that would constitute a breach of the
Code or Gilead’s other legal obligations. Applicants will be required to ensure that their activities in
connection with any funding received comply with the requirements of the Code.
Particular attention will be given to applications that promote or enable the active involvement
of patient groups or organisations in treatment, care or policy decisions.
Please read the ‘Guidance for applicants’ before filling in your application and answer all sections
below. If you have any queries about the application form, please email admin@gileadcommunities.com
1. Applicant’s information
Organisation
Contact names(s)
Job title
Department
Address
City
Postcode
Telephone (business)
Telephone (mobile)
Email
Registered Charitable
Organisation Number
Total gross earnings of your
organisation for the previous
tax year 2013/14
2. Requested funding
HIV
Hepatitis B
Hepatitis C
000/UK/14-12/MM/1034b · December 2014
3. Organisation overview
In under 100 words provide an overview of your organisation
Suggested headings to include here are:
Nature (policy/advocacy/support/information):
Geographical reach (local, regional, national):
4. Funding overview
In under 100 words provide an overview of what the funding will be spent on.
5. Funding details
In under 1,000 words describe what the funding will be spent on in more detail. Please read the
‘Guidance for applicants’ for advice on what to include. You may also include supporting evidence
with your application.
Suggested headings to include here are:
Your aims and objectives:
Why this funding is needed:
Target population:
Specific goals this funding aims to achieve (with timings):
How we will measure that the funding has made a difference:
How this funding fits in with our organisation’s overall activities:
Our organisation’s capacity to deliver the activities this funding is for:
Our organisation’s track record on delivering the activities this funding is for:
000/UK/14-12/MM/1034b · December 2014
6. Funding request
Amount requested:
Budget table:
Items
Total cost (£)
Amount requested from Gilead
Comments
Materials
Supervision
Overheads
Staff
Other (please specify)
Other (please specify)
Total
7. How did you hear of Gilead’s Community Grants Programme?
Please tick all that apply
Via Gilead personnel
Word of mouth
Previous grant applicant
Previous grant recipient
Gilead Communities website
Other, please state:
8. Acknowledgement
If successful, we undertake to ensure that all activity in connection with the project/funding is
compliant with the ABPI Code of Practice 2015 (www.pmcpa.org.uk/thecode/Pages/Download-theCode.aspx). In particular, we understand that the provision of a grant is not intended to, and shall
impose no obligation upon the Grantee to, promote or otherwise encourage the prescription,
recommendation, purchase, supply, sale or administration of the products of Gilead Sciences or its
affiliates.
If successful, we understand that funding is contingent on a formal grant agreement being signed
by the applicant.
If successful, we agree to provide reports after 6 months and 12 months to Gilead Sciences on the
progress and use of the funding and/or project.
Name
Date
Thank you for completing this application.
Please email it to admin@gilead-communities.com by 10 April 2015.
You will be notified when the application has been received.
000/UK/14-12/MM/1034b · December 2014