About | Educational, Charitable, and Fellowship Grants | Healthcare Professional Sponsorship ApplicationHealthcare Professional Sponsorship Application Healthcare Professional Sponsorship Application This application is intended for requests to sponsor residents and/or fellows’ attendance to third-party educational events. Please be sure you understand each of the following guidelines before submitting your request. The requestor must be a representative from the hospital/university on behalf of the resident or fellow who the grant is intended to support. The requestor cannot be a Globus Medical representative. In order for a resident to be eligible for funding, they must be PGY-4 or above. All complete requests must be submitted at least forty-five (45) days prior to the date of the event to be considered. The name of the healthcare professional who the grant is intended to support may not be listed in the application nor the application attachments. If you are unsure if you are completing the correct application, please reach out to grants@globusmedical.com for assistance Today's Date* MM slash DD slash YYYY Requestor Information Name* First Last Title* Institution* Institution 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 Phone*Email* Resident/Fellow*ResidentFellowResident Year* Event Information Event Name* Event Start Date* MM slash DD slash YYYY Event End Date MM slash DD slash YYYY Event Location* AttachmentsFormal Letter of Request*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx Brochure/Agenda for Event*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx W9*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx OtherAccepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx BudgetBudgetAccepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx Registration Fees Hotel: Number of Nights Hotel: Fee per Night Airfare Please ExplainPer Globus Medical Grants Policy, Educational Grants do support meal or ground transportation costs.Total Amount Requested