Society Conference Application

Requestor Name*

First Last

Requesting on behalf of:

Organization*

Tax ID Number

Make payable to:*

Attn:*

Payable Address

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

Primary Contact Name*

First Last

Title

Email*

Phone Number*

Program Name

Please explain specifically what you are requesting*

Requested Amount*

Program Start Date*

Program End Date (If applicable)

Estimated Number of Attendees*

Target Audience

Does the event offer Continuing Medical Education (CME) credits?*

Yes
No

Is there an exhibit opportunity?

Yes
No

Cost of Exhibit:

Is there a cadaver station?

Yes
No

How many stations are you requesting support for?

Cost per station:

Will Globus Medical Equipment be required?

Yes
No

Has Globus supported this event in the past?*

Yes
No

In what year? (YYYY)

In what amount?

Are you an affiliate of the United States government or military?*

Yes
No

Signed Letter of Request on Company Letterhead*

Budget (detailed summary of how funds will be used)*

Event Brochure (if applicable)

Program Agenda/Sponsorship Information*

W9 Form*

•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 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.

•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.

•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:*