Product Donation Product Donation Application The entity requesting funding should complete the below form in its entirety (unless there are translation needs), including the required paperwork noted below. 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 InformationWill both surgeon and hospital be donating their time and services?*If not, please explain why.YesNoNo, both surgeon and hospital be donating their time and services because:*Will the patient(s) be charged for any part of the surgery or treatment?*If so, please provide explanation.YesNoYes, the patient(s) will be charged for any part of the surgery or treatment because:*Will any third party be billed for any of the services or implants provided to the patient(s)?*If so, please provide explanation.YesNoYes, a third party be billed for any of the services or implants provided to the patient(s) because:*Provide summary of why implant donation is being requested.* If an indigent patient, please describe the circumstances.Description of implants and instruments being requested*Event Date* Event Location*Due Date*Commitment Deadline Is a monetary donation also being requested along with the implant donation?*If so, how much?YesNoRequest Amount*If a monetary donation is being requested, is there a budget for this event?*If so, please attached as stated below.YesNoName of K2M contact*(or name of contact who referred you if applicable) 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 Signed W-9 Form (US Only) IRS Determination Letter (501(c)(3) certificate) or equivalent documentation of tax exempt status Budget of Missions Trip, if applicable 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. 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.