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 MM slash DD slash YYYY 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Contact Name* First Last Title Email* Phone Number*Program Name Please explain specifically what you are requesting*Requested Amount* Program Start Date* MM slash DD slash YYYY Program End Date (If applicable) MM slash DD slash YYYY Estimated Number of Attendees*Target Audience Does the event offer Continuing Medical Education (CME) credits?* Yes No Is there an exhibit opportunity? Yes No Exhibit type*BoothTabletopCost of Exhibit: Is there a cadaver station? Yes No Will Globus Medical Equipment be required? Yes No How many stations are you requesting support for?*Cost per station:* Procedure Type?*ACDFTLIF / PLIFALIFLLIFVBTAnterior-to-PsoasTumorSIRoboticsApproach?ATP (MIS LLIF)Direct Look (MIS LLIF)Approach?MIS TLIFOpen TLIFEquipment?ELSA-ATPDirect LookOtherEquipment?Direct Look SetELSAMARS 3VL RetractorRise-LOtherEquipment?FortifyFortify-IMARS 3VL Retractor/MARSRevere Corrective OsteotomyCREO 5.5 DegenOtherEquipment?FortifyMARS ACDF RetractorQuartexXtendOtherEquipment?AlteraCREO MISMARS 3V SystemSignatureOtherEquipment?CREO 5.5 DegenMARS 3V SystemRIseAlteraOtherEquipment?IndependenceMagnify-SMARSIndependence MISOtherEquipment?CREO 4.75Thoracoscopic InstrumentsEquipment?SI-LOK InstrumentsSI-LOK ImplantsEquipment?ExcelsiusGPSIf other, please specify 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*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.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, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxEvent Brochure (if applicable)Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsxProgram Agenda*Accepted file types: allowedfiletypes:jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.Sponsorship InformationAccepted file types: allowedfiletypes:jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.W9 Form*Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB.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:*
