About | Educational, Charitable, and Fellowship Grants | Globus Cares ApplicationGlobus Cares Application 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 InformationRequestor InformationFirst Name*Last Name*Title*Email* Phone*Primary Contact Name (if different from requestor)First NameLast NameTitleEmail PhoneGlobus Medical Rep (if known)First NameLast NameEmail Request InformationDonation Type*Please SelectMonetaryIn-KindBothAmount Requested*Location for Mission Trip*Organization InformationName of Organization*Is the organization a valid 501 ©3?*YesNoWebsite* Employer ID Number (EIN, Tax ID)*Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Year Founded (YYYY)Is this a payable address?*YesNoIf no, please provide the payable information below: Payable toAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Organization's mission statement*Has the organization ever been audited by DOJ or other governmental authority?*YesNoIf yes, please explain.Are any spine surgeons members of the Board of Directors of the organization?*YesNoIf yes, please list members and their titles:Primary beneficiaries of organization's work?*Specific Mission Trip InformationWhat is the intended use of the funds requested?*Has Globus supported this event in the past?*YesNoIf yes, in what most recent year? (YYYY)For what type of donation?Please SelectMonetaryIn-KindBothFor what amount?Primary source of funding?Have you received donations from other corporate entities?*YesNoIf yes, what organizations?How many patients do you plan to treat?*Will there be time spent on non-surgical/mission specific activities?*YesNoIf yes, please explain.Are any members of the trip relatives?*YesNoIf 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?*YesNoDo you agree to verify usage for IRS authentication?*YesNoAttachmentsSigned Letter of Request on Company Letterhead*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxDetailed Budget*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxW9 Form*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxReport from Most Recent Mission Trip (if available)Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxEquipment List (if available)Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxOtherAccepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxList 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:*