About | Educational, Charitable, and Fellowship Grants | Educational Grants Application – Educational EventsEducational Grants Application – Educational Events The following application is intended for requests to support educational funding for a meeting, course, workshop, lab opportunity, or other event. If you are unsure if you are completing the correct application, please reach out to grants@globusmedical.com for assistance.Today's Date Date Format: MM slash DD slash YYYY Requestor Name* First Last Requesting on behalf of:Organization*Tax ID NumberMake payable to:*Attn:*Payable 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 Primary Contact Name* First Last TitleEmail* Phone Number*Program NamePlease explain specifically what you are requesting*Requested Amount*Program Start Date* Date Format: MM slash DD slash YYYY Program End Date (If applicable) Date Format: MM slash DD slash YYYY Estimated Number of Attendees*Target AudienceDoes the event offer Continuing Medical Education (CME) credits?*YesNoIs there an exhibit opportunity?YesNoCost of Exhibit:Is there a cadaver station?YesNoHow many stations are you requesting support for?Cost per station:Will Globus Medical Equipment be required?YesNoHas Globus supported this event in the past?*YesNoIn what year? (YYYY)In what amount?Are you an affiliate of the United States government or military?*YesNoSigned 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, xlsxBudget (detailed summary of how funds will be used)*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxEvent Brochure (if applicable)Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxProgram Agenda*Accepted file types: allowedfiletypes:jpg, pdf, doc, docx, csv, xls, xlsx.Sponsorship InformationAccepted file types: allowedfiletypes:jpg, pdf, doc, docx, csv, xls, xlsx.W9 Form*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx•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:*