About | Educational, Charitable, and Fellowship Grants | Employee Match Grant ApplicationEmployee Match Grant Application Employee Match Grant Application This application is intended for Globus Employees to submit requests for the Employee Match Program. Please be sure you understand the following guidelines prior to completing this application: In order to be eligible for this program, you must have been employed full-time at Globus for at least 1 year. Interns, co-ops, part time, temporaries, vendors and contract employees are not eligible for this program. Globus matches donations of at least $25 up to $500, 3:1 to eligible charitable organizations. For example, if you make a donation to the Red Cross for $100, Globus will provide a donation of $300 in your name. Globus matches gifts of cash, personal checks, credit cards, and securities with a quoted market value Gifts paid, not pledged, must have been made within the last twelve (12) months to qualify for a matching gift. Eligible employees may only submit a request for employee match once in a calendar year. Donations must be made to valid 501©3 organizations. Requests to support individuals directly will not be eligible. If you are unsure if you qualify for the program, please reach out to grants@globusmedical.com for assistance Today's Date* MM slash DD slash YYYY Employee InformationEmployee Name* First Last Employee Title* Employee Email* Employee Phone*First Year at Globus* Organization InformationOrganization Name* Organization Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Organization Contact Name Organization Contact Title Organization Contact Email In the event of an approval, a letter is emailed to this contact to let them know the amount that was approved and that you have submitted the request on their behalf. If you do not wish for Globus to provide this communication, please check the box. I do not wish for Globus to send a letter stating my request AttachmentsProof of Payment*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.This can be a photo of a deposited check, a confirmation of receipt from the organization, a screenshot of an online donation, etc. If you have questions, please feel free to reach out to grants@globusmedical.com. Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxW9 for the Organization*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.This is used to remit payment to the organization. Without this information, we are not able to provide payment. Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx The funds will be used only for the intended purpose of this request and will not be used in violation of any State or Federal Laws. This request was not made with the intention or possibility to influence or improperly benefit an official to appear more favorable. All information included on and documentation attached to this request form by the Requestor and/or Recipient is accurate. * Signature* Reset signature Signature locked. Reset to sign again
