Mission Trip Application

surgeon with device
  • Contact Information

  • Requestor Information
  • Primary Contact Name (if different from requestor)
  • Globus Medical Rep (if known)
  • Request Information

  • Organization Information

  • If no, please provide the payable information below:
  • Specific Mission Trip Information

  • Attachments

  • 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.