NCPA Foundation Disaster Relief Grant: Sponsored by Cencora Impact Foundation

The National Community Pharmacists Association (NCPA) Foundation Disaster Relief Fund was established to provide financial assistance to community pharmacy owners for the repair of pharmacies in the event of disaster, accidents, illness, or other adverse circumstances. Through a grant from Cencora Impact Foundation, funds are available to NCPA member and nonmember independent pharmacies. Applicants are also eligible for additional funds through NCPA Foundation supplemental grants. Upon submission and review of this form, you will be asked to provide proof of damage (e.g., copy of signed and dated insurance claim form, photo of damage) by NCPA Foundation staff. Please note that photos may be used for promotional purposes and by submitting the photos, you agree the Foundation and its partners may use them for this purpose.

If you have any questions or need additional help with the application, please contact 703-838-2653 or email ncpaf@ncpa.org.

1. Contact Information: *This question is required.

First Name

Last Name

Title

Pharmacy Name

Street Address

City

State

Zip

Email Address

Phone Number

Mobile Phone

2. Tax ID # *This question is required.

3. Pharmacy License Number *This question is required.

4. Name of Wholesaler *This question is required.

5. Reason for requesting financial assistance: *This question is required.

Please enter an 'other' value for this selection.

6. Explain the type of damage or negative impact to your independent/community pharmacy: *This question is required.

7. How will this grant be used to help your business? *This question is required.

8. What is your insurance deductible? (enter: “Not Covered” if applicable) *This question is required.

9. Approximate date of damage: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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10. How would you prefer to be contacted? *This question is required.