Mission Trip Application | Globus Medical

The following application is intended for requests to support Surgical Mission Trips. Please be sure you understand each of the following guidelines before submitting your request.

Globus is unable to provide a donation if the trip is not supported by a 501(c)(3) organization. Approved funding cannot be issued to an individual.
The focus of the trip must be on the treatment of patients, free-of-charge, with spinal pathologies, that otherwise would not receive care, and where appropriate may include the educating of spine surgeons servicing the region.
Through the Globus Cares Program, we aim to support missions to as many different locations as possible in a calendar year. As such, support to the same locations may be limited. Please reach out to grants@globusmedical.com prior to the completing an application to determine if a particular location is still open for applications in the given year.
Requests must be submitted AT LEAST 3 months (12 weeks) prior to the intended dates for the trip.

If you are unsure if you are completing the correct application or if you are eligible for the Globus Cares Program, please reach out to grants@globusmedical.com for assistance.

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

Trip Date*

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