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Request for Support

Name and Contact Information of Individual Making the Request
Reason for the Request
Does your organization provide services or support for our patients and/or does your organization provide research funding to UK or UK HealthCare? Yes/No
If yes, please describe how you provide support and dollar amount of funding, if applicable.
Were you referred by someone? Yes/No
If yes, who?
Have you submitted any other requests from other departments within UK HealthCare or the University of Kentucky? Yes/No
If yes, who?


Note: Future consideration requires all organizations to report previous year's results along with submission. All requests will be evaluated based on alignment with UK HealthCare and/or the University of Kentucky strategic priorities.

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