Mission Trip Application | Globus Medical

Contact Information

Requestor Information

First Name*

Last Name*

Title*

Email*

Phone*

Primary Contact Name (if different from requestor)

First Name

Last Name

Title

Email

Phone

Globus Medical Rep (if known)

First Name

Last Name

Email

Request Information

Donation Type*

Amount Requested*

Location for Mission Trip*

Organization Information

Name of Organization*

Is the organization a valid 501 ©3?*

Yes
No

Website*

Employer ID Number (EIN, Tax ID)*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Year Founded (YYYY)

Is this a payable address?*

Yes
No

If no, please provide the payable information below:

Payable to

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Organization's mission statement*

Has the organization ever been audited by DOJ or other governmental authority?*

Yes
No

If yes, please explain.

Are any spine surgeons members of the Board of Directors of the organization?*

Yes
No

If yes, please list members and their titles:

Primary beneficiaries of organization's work?*

Specific Mission Trip Information

What is the intended use of the funds requested?*

Has Globus supported this event in the past?*

Yes
No

If yes, in what most recent year? (YYYY)

For what type of donation?

For what amount?

Primary source of funding?

Have you received donations from other corporate entities?*

Yes
No

If yes, what organizations?

How many patients do you plan to treat?*

Will there be time spent on non-surgical/mission specific activities?*

Yes
No

If yes, please explain.

Are any members of the trip relatives?*

Yes
No

If yes, who are they and what will their responsibilities be?

Do you agree to submit a post mission report, along with pictures to Globus within 30 days of trip completion?*

Yes
No

Do you agree to verify usage for IRS authentication?*

Yes
No

Attachments

Signed Letter of Request on Company Letterhead*

Detailed Budget*

W9 Form*

Report from Most Recent Mission Trip (if available)

Equipment List (if available)

Other

List of Mission Participants*

Compliance Agreement:

•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. No third party reimbursement will take place for any services rendered during the medical mission trip.

•No product(s) will be sold during the medical mission trip.

•All unused product will be returned to Globus Medical, Inc.

•No Globus employee implicitly or explicitly offered a contribution to induce the Recipient, its personnel, or me to purchase, use, order, or recommend Globus products or to reward prior purchases, uses, orders, or recommendations of Globus products.

•The funds awarded will not be used in violation of any healthcare code of ethics.

•Globus Medical reserves the right to request the return of award at any time upon failure to comply with procedures and legal regulations.

•A post trip report will be submitted within 30 days of your return.

•All information included on and documentation attached to this request form by the Requestor and/ or Recipient is accurate.

By signing below you agree to these terms:*