Fellowship Grant Fellowship Grant Application 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 InformationRequesting Sponsor*Organization NameFirst Name*Last Name*Country*Please Select...United StatesAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweAddress 1*Address 2City*State*Please Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonZip Or Postal Code*Email Address* Primary Phone Number* Request InformationProgram/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 programAll 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 attachedOrganization*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 belowAll surgeon instructors for this fellowship program should be listed, if needed a separate document may be attached. Surgeon Name 1*K2M Consultant?*YesNoSurgeon Name 2K2M Consultant?*YesNoSurgeon Name 3K2M Consultant?*YesNoSurgeon Name 4K2M Consultant?*YesNoSurgeon Name 5K2M Consultant?*YesNoSurgeon Name 6K2M Consultant?*YesNoSurgeon Name 7K2M Consultant?*YesNoSurgeon Name 8K2M Consultant?*YesNoSurgeon Name 9K2M Consultant?*YesNoSurgeon Name 10K2M Consultant?*YesNo Fellowship Budget InformationRequest 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 QuestionsPlease respond to the below questionsDoes the requesting organization have a government affiliation*If yes, please describe the government affiliation:YesNoIf 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:YesNoIf yes, please describe activities:Is the fellowship program accredited by a state or country medical society?*If no, please explain (and attach program guidelines):YesNoIf no, please explain (and attach program guidelines):Is the fellow or apprentice employed full time by the sponsoring institution?*If no, please explain:YesNoIf no, please explain:Is the requesting institution hosting the fellow?*YesNoIf no, please explain: Required DocumentsAttach 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 applicableIf 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.*Accepted file types: pdf. CertificationsPlease 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*CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.