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Donation and Subsidy Request

Medtronic Ear, Nose and Throat (ENT) Policy

Medtronic ENT makes donations to tax-exempt charities in order to:

  • benefit society;
  • promote better health care;
  • demonstrate good corporate citizenship;
  • serve a genuine educational function.

In addition, Medtronic ENT provides subsidies:

  • to other organizations or institutions sponsoring scientific medical conferences or meetings; or
  • for health care professionals in training.

Approval of such donations and subsidies will be made on the basis of a number of general and specific factors; and the requests must be in compliance with Medtronic ENT Business Conduct Standards and the AdvaMed Code of Ethics.

Documentation
Medtronic ENT requires that the Request Form be complete and all supporting documents be submitted before review.

  • Scroll through this Request Form to understand the information and documents necessary for submission.
  • Complete and Submit the Form, making sure to attach all required supporting documentation.  (Read our FAQs)

Process

  1. The Medtronic ENT BCS Coordinator will be your point of contact for any questions you may have. You will be notified if your submission is incomplete.
  2. All requests will be reviewed by the Medtronic ENT Donations and Subsidy Committee.
  3. Medtronic ENT will notify you of our decision within 45 days of receiving a complete request. This time frame allows Medtronic ENT to carefully review each request.

Please Note: If you leave this form idle for a period of 1 hour or more, the form will timeout and any information entered will be lost and you will need to re-enter it.

* Required Information

Receiving Organization

*Full legal name of Receiving Organization:

*Street Address:

*City/State/Zip:

 / /

*Federal Tax ID no.

*Is the organization tax-exempt?

Yes     No
 

Proof of the receiving institution's tax-exempt status, e.g., 501(c)(3), choose one:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

Not required if request is for a subsidy of a scientific or medical education meeting.

*Receiving Organization Contact:

Position/Title:

*Phone:

- -

Alternative Phone:

- -

Fax:

- -

*Email Address:

(Used for correspondence regarding the request.)

*Date Decision Needed:

/ / Show Calendar

Note: Upon receipt of complete documentation, Medtronic ENT requires 45 days to review and will notify you of the decision.

   

Requestor Information

*Are you an employee of the Receiving Organization?

Yes     No
 

If you are not an employee of the Receiving Organization, please complete the following information.

*Name:

*Position/Title:

*Primary institution:

*Address:

*City/State/Zip:

 / /

*Phone:

- -

Alternative Phone:

- -

Fax:

- -

*Email Address:

(Used for correspondence regarding the request.)

*Relationship to receiving organization (Describe nature of relationship and note specifically if you are on the board, receive compensation from, or have an investment interest in the receiving organization):

   

Event or Activity for Which You Seek Funding

Requests for research support should be made on a separate Research Request Form, available at http://mxo-donation.com

*Name of Event:

*Please choose one event or activity:

Charitable Fundraiser (Medtronic ENT has limited funds for these types of events.)
 

*a.

 Event date: / / Show Calendar
or if multiple dates:

*b.

Event venue:

*c.

Location of the event (city/state): /

*d.

Attach a copy of event invitation and any additional informational materials about the event that you have produced, choose method:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

*e.

To what purpose will the funds be applied?

*f.

Is an event (e.g. golf, dinner) part of the cost?
No     Yes, describe:

*g.

Does the event also involve an opportunity for medical device companies to set up and operate informational booths on their products or therapies or to place advertisements in the event program?
No    Yes, describe:

Educational Conference, Round Table, Congress, Lab Workshop or other meeting sponsored by receiving organization
 

*a.

 Event date: / / Show Calendar
or if multiple dates:

*b.

Event venue:

*c.

Location of the event (city/state): /

*d.

Does the meeting involve specific training on how to use or operate Medtronic ENT products?
No Yes, describe:

*e.

Attach a copy of the meeting agenda and program, choose method:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

*f.

Does your request include the use of any Medtronic ENT product(s)?
No Yes, complete the Product Request Form listing a description of the products and quantities requested, choose method:

*

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

*g.

Will CME or CEU or educational credits be provided?    Yes No

 

*Specify number of credits:
*Specify the credit charge to attendee (or portion of registration fee directed to credits):

*h.

In the event your funding request is approved, will you require a Letter Agreement signed by Medtronic ENT?
No Yes, attach Letter Agreement form, choose method:

*

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

*i.

Will a portion of the amount requested go to the purchase of booth space or an advertisement?
No Yes, If "Yes" please specify booth fee or advertisement amount: $ and describe:

Grand Rounds
 

*a.

 Event date: / / Show Calendar
or if multiple dates:

*b.

Event venue:

*c.

Location of the event (city/state): /

*d.

Speaker(s):

*e.

Speakers' Organization:

*f.

Attach agenda, choose method:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

Other educational purposes; Specify:

Mission Trip (Completion of the Funding Request section is not required for Mission Trips)
 

*a.

 Trip date: / / Show Calendar
or if multiple dates:

*b.

Location (city/country): /

*c.

Brief description of trip:

*d.

Complete the Product Request Form listing a description of the products and quantities requested, choose method:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

*e.

Detail how the donation will be used:

*f.

Attach letter from Charitable Organization (on their letterhead) detailing request, choose method:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

Other; Specify:

Funding Request:

*1.

*Total amount of donation or subsidy requested: $ (Do not use dollar signs or commas.)

* Complete the Budget Form with a detailed budget showing the costs of the event or activity, choose method:

Attach file (you will be prompted to upload from the next page.)

Fax
To submit attachment by fax see point of contact for more information.

Email
 To submit attachment by email, see point of contact for more information.

*2.

Will the requested Medtronic support be used to cover overall costs or more specific items?
Overall costs     More specific items, specify:

*3.

What portion of the funding is tax deductible?

*4.

How will any non-tax-deductible amount be used?

*5.

Is support being requested from other companies, organizations or other Medtronic Divisions? If so, please list them.

*6.

To what use will any surplus funds be directed? Describe:

*7.

Detail how the donation or subsidy will be used and why it furthers the charitable or educational purposes of the Receiving Organization:

In order to Review and Submit your donation and subsidy request click Continue.

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