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