November, 1 2002

Office of Financial Management

SPONSOR CERTIFICATION

The Food and Drug Administration requires the following information to be completed by sponsoring organizations requesting FDA employees to attend, participate in, or speak at non-federal meetings, conferences, and symposiums.

NAME OF SPONSOR ISSUING INVITATION:
___________________________________
___________________________________

SPONSOR MISSION STATEMENT:
___________________________________
___________________________________
___________________________________

TARGET AUDIENCE:
___________________________________
___________________________________

PURPOSE FOR WHICH THE FDA EMPLOYEE IS BEING INVITED:
___________________________________
___________________________________

NAME OF FDA EMPLOYEE:
___________________________________

NATURE OF COSTS TO BE REIMBURSED TO FDA (i.e., airfare, lodging, meals. miscellaneous expenses):
___________________________________

Additional Certification:

Yes ____
No ____
Is the traveler an officer, director, trustee, board member, partner or an employee of the sponsoring organization?

Yes ____
No ____
Does the traveler’s Center/Office have a contract or grant with the sponsoring organization?

Yes ____
No ____
Is the sponsor (or a component of this sponsoring organization) party to a matter, which is pending before the FDA?

Yes ____
No ____
Is the sponsor a for-profit organization?

Yes ____
No ____
Does the sponsor engage in any lobbying activities?

Yes ____
No ____
Does the sponsor include corporate as well as individual membership? if so, how many and what is the percentage of corporate members?

WE ALSO AGREE TO THE FOLLOWING:

Nne of the funds that will be used to support these travel costs come from any federal grants or from any contracts with the Department of Health and Human Services, or from the regulated industry or trade associations.

We also understand that FDA requires that its employees pay directly for all of their travel costs and that we will be billed for these costs by FDA after the trip has been completed and the traveler’s claim has been submitted to FDA. We further understand FDA’s requirements that costs of employee travel accommodations may not be subsidized in any way, and assure that we will comply with that policy. Any room charges that are arranged for FDA employees by our organization will not be less than the hotel would normally charge to the traveling public, with the sole exception of volume discounts made available to us by the hotel. Our organization will not otherwise arrange for or make any additional payments to the hotel to defray room costs for FDA employees.

Name: (Please Print) ___________________________________

Title: ___________________________________

Signature: ___________________________________
Date: ___________________________________

Budget Formulation - Budget Execution - Financial Systems – Applications – Accounting – Travel - Payroll 5600 Fishers Lane, Rockville, MD 20857, HFA-100, 301-827-5001

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