Globus Medical Fellowship Application

Institution Name*
Institution Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Institution's Fed ID #
Is This program ACGME accredited?
- Yes
- No
Is the 501(c) (3) letter and W9 form attached?
- Yes
- No
Fellowship Start Date
Fellowship End Date
Requestor Name
First Last
Requestor Title
Requestor Email Address*

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Fellow Name*
First Last
Fellow Email Address*
Fellow Name
First Last
Fellow Email Address

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Fellowship Program Director*
First Last
Fellowship Program Director Email Address
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone
Fax
Department Chairman Name
First Last
Department Chairman Email Address*
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone

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Applicant Certification and Acceptance:*
I Accept
I certify, on behalf of the applicant, that the statements herein are true, complete and accurate to the best of my knowledge, and accept the obligation to comply with Globus Medical, Inc.’s terms and conditions if a grant is awarded as a result of this application. I further certify that the applicant understands that any deliberate omission or the misrepresentation or falsification of any of the information contained in this application or in any other communication by the applicant to Globus Medical, Inc. related to this application may void any grant awarded to the applicant institution by Globus Medical, Inc. and may require the applicant institution to refund any such grant.
Signature of Fellowship Program Director:*
Date*
MM slash DD slash YYYY
Signature of Department Chairman:*
Date*
MM slash DD slash YYYY

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Fellowship Program Coordinator Name*
First Last
Fellowship Program Coordinator Email Address
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Telephone
Fax

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Alternate Contact Name*
First Last
PROVIDE THE NAME AND CONTACT INFORMATION FOR AN ALTERNATE CONTACT – This is the person Globus Medical, Inc. should contact if there is a question regarding the application and the Program Director cannot be reached (administrative assistant, etc.)
Alternate Contact Email Address*
Telephone

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Financial Officer Name*
First Last
Financial Officer Email Address*
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code Country
Telephone

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Check Payable To (must be name of Institution)
Amount Requested
Mailing Address For Check
Street Address City State / Province / Region ZIP / Postal Code Country
Name of person to receive check*
First Last

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Fellow’s Qualifications:
Please provide the following information on the fellow who has been selected (please attach CV when submitting application)
Briefly describe the fellow selection process.

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Number of fellowships per year
Length of the fellowship (include dates of fellowship)
Number of years the fellowship program has been in place
Total number of fellows trained since program was established
Therapeutic area of focus?
Total number of spine surgeries per year at institution
Is this organization of a charitable or academic affiliation?
- Yes
- No
Name of the teaching institution with which this Fellowship program is affiliated
Are the fellowship objectives/curriculum attached to this application?*
- Yes
- No
Is the Fellowship program accredited?
- Yes
- No
If so, by which accrediting body and when?

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Fellow Appointment
Provide a concise overview of the educational program, highlighting key inpatient and outpatient facilities, didactic activities, research activity, and any unique features of your program.
Fellow Education
Concisely describe opportunities for fellows to provide consultation with faculty supervision. In addition, describe fellow educational responsibilities for residents, medical students, and allied health personnel.

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Rotations
Describe each of the current fellows’ rotations. If there are no current fellows, describe the rotations of the most recent fellows. Include in each description the main educational focus, the supervising faculty, and the key facilities that contribute to fellow education. Add additional rows and pages as necessary.

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Describe the time free of clinical duties that is provided for fellow participation in clinical or laboratory work.
Articles:
List the articles authored or co-authored by fellows in your program that have been published in referred journals during the last three years. (Note: The fellow must have been in your program while doing the research, but no necessarily when the article was published).

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Describe the program conference schedule, including the levels of teaching staff participation and fellow attendance. Include a list of the program conferences that were held last year.
List the local, regional, and national meetings attended by fellows during the last 12 months.

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Concisely summarize the manner in which fellows are evaluated (including how feedback is provided to promote improvement in fellow performance).
Provide a frank assessment of (a) program strengths, (b) program needs, and (c) plans to address those needs in the future.

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List each faculty member associated with this fellowship. Describe their qualifications and role in the program. Please limit response to one paragraph per faculty member.
Include a two-page Biographical Sketch for all faculty. This may not exceed two pages for each person. Be sure to include experience relevant to the program. Please include the following information: Name, position/title, education/training, degrees, year(s), field(s) of study, professional experience.

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Have you applied for funding for this Fellowship from other funding sources?
- Yes
- No
If yes, please state source.
If yes, have you received funding for this fellowship?
- Yes
- No

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Please provide a line item justification of the amount requested for the fellowship sponsorship.
Expenses Estimated Cost

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Conflict of Interest Signature (must be signed by Fellowship Program Director or Department Chairman)*
I hereby certify, on behalf of the Applicant, that this Conflict of Interest Disclosure Form (the “Form”) accurately sets forth all of the known relationships between the Applicant and any Globus Medical, Inc. representative and that I have completed this Form fully and accurately in all respects.
Date*
MM slash DD slash YYYY
Print Name*
First Last
Title

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Please include with your application: a copy of fellowship objectives/curriculum and the CV’s of relevant teaching faculty, as well as the fellow’s CV.
- The process time may be lengthy. It is anticipated that there should be up to 8 weeks allowed to process applications.
- Applicants may be asked to have a phone interview with Globus Medical Review Committee as part of the decision making process.
- Applicants will be notified via email as to the Globus Medical’s decision regarding their application.
- All applications are due by June 1st to be considered for the next academic year.
- Submission of this form does not guarantee distribution of funds.
Questions: Please contact Globus Medical Professional Affairs:
Lisa Taylor-Osley Director, Professional Affairs
Email

Phone: 610-930-1800 x 3239
FAX: 610-930-2042
Requestor Signature*
Date*
MM slash DD slash YYYY
Date*
MM slash DD slash YYYY
File
Drop files here or

Accepted file types: jpg, pdf, doc, docx, csv, xls, xlsx, Max. file size: 50 MB, Max. files: 10.
Allowed file types: jpg, pdf, doc, docx, csv, xls, xlsx

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Expenses	Estimated Cost

Globus Medical Fellowship Application

Globus Medical Fellowship Application

Step 1 of 20 – Applicant Institution Information