Fellowship Grant

The entity requesting funding should complete the below form in its entirety (unless there are translation needs). K2M Sales Representatives are prohibited from filling out this form. Requests that are not completed using the fields below (e.g. a handwritten form) will not be considered.

General Information

Requesting Sponsor*

Organization Name

First Name*

Last Name*

Country*

Address 1*

Address 2

City*

State*

Zip Or Postal Code*

Email Address*

Primary Phone Number*

Request Information

Program/Project Name*

Program/Project Description*

Program Date*

Program Specialty*

Number of fellows in the program*

Total fellows in the program for the last 3 yrs*

Number of fellows at the institution per year*

Please list the research the fellows will complete*

Number of presentations required of each fellow*

Number of publication submissions required of each fellow*

Name of K2M contact*

(or name of contact who referred you if applicable)

Past Fellowship Support received from K2M

(if any) (please include dates)

Please list support requested or obtained from other funders for fellowship program

All funding requests related to the program specialty above and the time frame of the request should be listed, if needed a separate document may be attached

Organization*

Request Amount*

Status of Request*

Organization*

Request Amount*

Status of Request*

Organization*

Request Amount*

Status of Request*

Please list the surgeons the fellow(s) will work with below

All surgeon instructors for this fellowship program should be listed, if needed a separate document may be attached.

Surgeon Name 1*

K2M Consultant?*

Yes
No

Surgeon Name 2

K2M Consultant?*

Yes
No

Surgeon Name 3

K2M Consultant?*

Yes
No

Surgeon Name 4

K2M Consultant?*

Yes
No

Surgeon Name 5

K2M Consultant?*

Yes
No

Surgeon Name 6

K2M Consultant?*

Yes
No

Surgeon Name 7

K2M Consultant?*

Yes
No

Surgeon Name 8

K2M Consultant?*

Yes
No

Surgeon Name 9

K2M Consultant?*

Yes
No

Surgeon Name 10

K2M Consultant?*

Yes
No

Fellowship Budget Information

Request Amount*

Number of fellows funded by the request amount*

Salary*

Medical Insurance*

Liability Insurance*

Textbooks*

Other budget costs 1*

(List line item with cost)

Other budget costs 2*

(List line item with cost)

Other budget costs 3*

(List line item with cost)

Other budget costs 4*

(List line item with cost)

Total fellow cost*

Additional Questions

Please respond to the below questions

Does the requesting organization have a government affiliation*

If yes, please describe the government affiliation:

Yes
No

If yes, please describe the government affiliation:

Will any of the fellow's time be billed to a third party for payment?*

If yes, please describe activities:

Yes
No

If yes, please describe activities:

Is the fellowship program accredited by a state or country medical society?*

If no, please explain (and attach program guidelines):

Yes
No

If no, please explain (and attach program guidelines):

Is the fellow or apprentice employed full time by the sponsoring institution?*

If no, please explain:

Yes
No

If no, please explain:

Is the requesting institution hosting the fellow?*

Yes
No

If no, please explain:

Required Documents

Attach the below documents as one pdf to your request. Requests submitted without the below documentation may not be reviewed. Attachments in versions other than PDF will be discarded by the online system.

Signed Letter on Requesting Organization's Letterhead
Accreditation Verification and copy of Notification Letter, if applicable
If accreditation is pending provide copies of correspondence with accreditation entity and time frame for accreditation
Written Fellowship Guidelines, Program Description, and Selection Criteria
Fellow's Schedule including time allocations for surgery, research, weekly meetings, rounds, and all other scheduled activities

Please choose a single PDF containing all required documents and additional information.*

Certifications

Please type your name and title below to certify that you agree to the terms listed below and that all information provided in and attached to this form is accurate.

I/we hereby certify that:

The funds will not be routed to a third party banking institution located outside of the country where the recipient is based or doing business.
Employees, officer, and/or directors of the company do not have family or other ties to government officials.
A government official has not designated the grant amount or will be a recipient of the funding either directly or indirectly.
This grant is not being made with the understanding that this payment could influence government action or improperly lead an official to look more favorably on the donor
The recipient will not provide gifts, travel, lodging, meals or entertainment to government officials in connection with charitable activities.
This grant will not be used in part or in whole to hire third parties who have connections to government officials or who have been identified or suggested by government officials.
The funds awarded in this letter will not be used in violation of any State and Federal Laws, including any anti-corruption laws and Anti-Kickback Statute.
The funds awarded will not be used in violation of the AdvaMed or any other applicable code of ethics on interactions with healthcare Professionals and ACCME guidelines.
The award will be returned at any time upon request for your organization's failure to adhere to applicable laws, K2M policy or procedural requirements, or your organization's stated use for such funds.
The requested donation/grant meets your internal guidelines for such funds.
A follow-up report will be provided within 90 days of the event's completion.
Any applicable professional fees for the fellow's services will be billed by and retained by the institution.

Name*

(Full Signature)

Title*

Comments

This field is for validation purposes and should be left unchanged.

Fellowship Grant