Create New Account

This portal is intended for organizations applying for grants or sponsorships to create an account that will allow them to access the ViiV Grants and Donations and Event Sponsorships page.

Please complete the following form. You will not be able to save the form without providing ALL required fields.

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In selecting a password remember that all passwords must include at least 12 characters. The characters must include and at least 1 of each of the following: number, UPPER case, lower case, and symbol.

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If you are associated to an Institution, type in the field below and select from the popup.
If your Institution is not on the list, please contact us.

Additional Contact Information

Comments:

Conflict of Interest Disclosure - Individual Representative of Organization Job Title:

Do you hold any position in government agencies?

Please provide details about why you answered the previous question "Yes":

Do you, or your immediate relatives (e.g. spouse, parents, children or siblings) have any ownership control interest in an entity that provides services or products to, or on behalf of ViiV Healthcare?

Please provide details about why you answered the previous question "Yes":

Do you, or your immediate relatives (e.g. spouse, parents, children or siblings) have any ownership interest in an entity that does business with the Government?

Please provide details about why you answered the previous question "Yes":

Do you, or your immediate relatives (e.g. spouse, parents, children or siblings) have any ownership control interest in an entity that could have influence over ViiV Healthcare's commercial business?

Please provide details about why you answered the previous question "Yes":

Do you, or your immediate relatives (e.g. spouse, parents, children or siblings) have a role which involves making decisions, or advising on, or influencing decisions on the regulation or procurement of medicines, or the funding or provision of Healthcare?

Please provide details about why you answered the previous question "Yes":

If other members of your organization will be involved in implementing the grant, please confirm that, to the best of your knowledge, no conflicts of interest exist with the individuals.

Specific Conflict Of Interest Queations - Organization Does your organization have any senior management, founder, or Board of Directors who could have influence over ViiV Healthcare's commercial business?

Please provide details about why you answered the previous question "Yes":Does your organization have any senior managment who hold any position in goverment agencies or entities (i.e. Ministry of Health)?

Please provide details about why you answered the previous question "Yes":For those members of senior management team, members of the Board of Directors, and key individuals who will be responsible for implementing the grant, is somebody currently, or has someone been, a Government Official in the past 2 years, being in a position that may influence the decisions or actions regarding the proposed contracts or the business activities of ViiV Healthcare or of its affiliates?

Please provide details about why you answered the previous question "Yes":Please state if among the persons mentioned above whether there is a person who has a business relationship or has a close family member (e.g. spouse, children, parents, siblings) with a Government Official who might be in a position to influence the purchase of ViiV Healthcare products or to offer a commercial advantage to your business or ViiV Healthcare?

Please provide details about why you answered the previous question "Yes":Do you intend to use any other companies, including subcontractors, subsidiaries, branches, partnerships or associations or other parties in addition to your own people who are not identified in your proposal to help implement the grant?

Please provide details about why you answered the previous question "Yes":

Request for data privacy consent If you have responded to any of the questions above, by saving and submitting this declaration

you consent to GSK/ViiV using information you provide about your response to carry out the conflict ofinterest check; and
you confirm that if your response is connected to a close family member, you have their consent to provide their information to GSK/ViiV for the same purpose.

This form may capture sensitive information, such as health or HIV status, or any other sensitive personal information you may choose to disclose. We will only process this information to assess your actual or perceivedconflicts of interest. Further information relating to how GSK/ViiV Healthcare will process your personal information can be found in the privacy notice.

I agree to GSK/ViiV processing my personal information as set out in this conflict of interest form.

Consent can be withdrawn at any time. Please see the privacy notice for further information.

Verification Please enter todays date to verify that that all information is correct as of this date.

Version G&D 20240618

Express Consent Collection Statement

This site will allow you to establish a personalized account for the purpose of interacting with ViiV Healthcare. To create a personalized account, you must provide some personal data, including your name and email address. ViIV Healthcare will use the information you submit to maintain your account, to automatically complete other forms on the Site, and otherwise as described in our Privacy Notice.

By clicking the I AGREE button and/or submitting your request, you acknowledge and agree to the following terms:

You are confirming that you have reviewed the Privacy Notice.
You agree not to submit through this portal any information that identifies or could be used to identify a patient, including the patient’s name or initials, address, date of birth, government-issued identification number, race or ethnicity, gender, or sexual orientation.
You agree not to submit any safety information through this portal. Any safety information, such as adverse event information, will instead be submitted using the hyperlinks or other contact information provided.
You acknowledge that ViiV Healthcare reserves the right to correct any administrative or technology-based errors that may occur during the request or review process.

Please refer to the Privacy notice section, "How to contact us" for direct contact information.

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Create New Account

Express Consent Collection Statement

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