Medtronic Diabetes Donation and Subsidy Request

Medtronic Policy
Medtronic Diabetes makes donations to tax-exempt charities in order to benefit society and promote better health care, demonstrate good corporate citizenship, and serve a genuine educational function. In addition, Medtronic Diabetes provides subsidies to other organizations or institutions sponsoring scientific medical conferences or meetings to underwrite the costs of such meetings or subsidize the attendance of health care professionals in training. Selection of recipients for such donations and subsidies will be made on the basis of a number of general and specific factors including: a direct and immediate connection to improving patients' lives or patient access to care in a therapeutic area of interest to Medtronic Diabetes; a unique contribution in such an area to the care of a particular patient group or an underserved population; and the quality of and need for the proposed educational opportunity. Donations and subsidies will only be made in compliance with Medtronic's Business Conduct Standards and the AdvaMed Code of Ethics.

Process

  1. Please read through this Donation and Subsidy Request Form to understand the information and documents required for completion.
  2. Fill out the Form completely, and gather all documents required by the Form.
  3. Submit the completed Form and supporting documents.
  4. The Medtronic Diabetes Contract/Grant Administrator will notify you if your submission is incomplete, and specify additional information that may be required.
  5. The Medtronic Diabetes Contract/Grant Administrator will be your point of contact for any questions you may have.
  6. All proposals will be reviewed by the Medtronic Donations Committee or Education Director, as appropriate.
  7. The Medtronic Diabetes Contract/Grant Administrator or the Education Director will notify you of Medtronic Diabetes decision.

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 a tax-exempt charitable organization?

Yes     No
 

Please provide your W-9 "Request for Taxpayer Identification Number and Certification" reflecting your tax status, 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.

If you need a W-9 form, please click here.

*Receiving Organization Contact:

Position/Title:

*Phone:

- -

Alternative Phone:

- -

Fax:

- -

*Email Address:

*Date Decision Needed:

/ / Show Calendar
   

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:
(Business unit for Medtronic employees)

*Address:

*City/State/Zip:

 / /

*Phone:

- -

Alternative Phone:

- -

Fax:

- -

*Email Address:

*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

*Name of Event:

*Please choose one event or activity:

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

*a.

To what purpose will the funds be applied?

*b.

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

*c.

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:

*d.

Event date:

/ / Show Calendar (Enter first day if multi-day event.)
Or if multiple dates:

*e.

Event venue:

*f.

Location of the event (city/state): /

*g.

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.

*h.

Proof of the receiving organization's tax-exempt status, e.g., IRC Section 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.

CME, CEU Event (Continuing Medical Education, Continuing Educational Units, or other professional education credits) sponsored by receiving organization (e.g. Grand Rounds; other meetings)
 

Educational Event (Offering Education Credits)

Grand Rounds
 

*a.

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

*b.

In the event your funding request is approved, will you require a Letter of Support Agreement signed by Medtronic?
No Yes, attach Letter of 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.

*c.

Is there an opportunity to exhibit at this event?
No Yes, If "Yes" please specify minimal amount to exhibit: *  $ and *describe:

*d.

Event date:

/ / Show Calendar (Enter first day if multi-day event.)
Or if multiple dates:

*e.

Event venue:

*f.

Location of the event (city/state): /

*g.

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

*h.

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.

*i.

Anticipated number of attendees:   

*j.

Target Audience; please provide anticipated audience breakout by specialty (Example: 10 general practice, 20 specialized (name specialty), 10 nurses):
 

*a.

Event date:

/ / Show Calendar (Enter first day if multi-day event.)
Or if multiple dates:

*b.

Event venue:

*c.

Location of the event (city/state): /

*d.

Speaker(s):

*e.

Speakers' Organization:

*f.

Attach agenda, program or invitation, 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 of Support Agreement signed by Medtronic?
No Yes, attach Letter of 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.

Anticipated number of attendees:   

*j.

Target audience; please provide anticipated audience breakout by specialty (Example: 10 general practice, 20 specialized (name specialty), 10 nurses):

*k.

Topic:

Non-Accredited Meeting, Conference, Round Table, Congress or Other Meeting sponsored by receiving organization (no educational credits - if credits are given, please select "CME, CEU Event" option above)
 

*a.

Is there an opportunity to exhibit at this event?
No Yes, If "Yes" please specify minimal amount to exhibit: *  $ and *describe:

*b.

Event date:

/ / Show Calendar (Enter first day if multi-day event.)
Or if multiple dates:

*c.

Event venue:

*d.

Location of the event (city/state): /

*e.

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

*f.

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.

*g.

Anticipated number of attendees:   

*h.

Target Audience; please provide anticipated audience breakout by specialty (Example: 10 general practice, 20 specialized (name specialty), 10 nurses):

Other Educational Purposes without CME / CEU credits; Please specify (e.g. video, publication or film)
(If credits are given, please select "CME, CEU Event" option above):

 
*

a.

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

None

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.

*b.

Proof of the receiving organization'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.

c.

Anticipated number of attendees:   

d.

Target Audience; please provide anticipated audience breakout by specialty (Example: 10 general practice, 20 specialized (name specialty), 10 nurses):

Advocacy or Lobbying Activities; Specify:

 
*

a.

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

None

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.

*b.

Proof of the receiving organization'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.

c.

Anticipated number of attendees:   

d.

Topic, if applicable:

e.

Target Audience; please provide anticipated audience breakout by specialty (Example: 10 general practice, 20 specialized (name specialty), 10 nurses):

Other; Specify:

 
*

*

Proof of the receiving organization'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.

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

Funding Request:
 

*Total amount of donation or subsidy requested: $

*1.

Send a detailed description of the 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 Diabetes support be used to cover overall costs or 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:

In order to Review your funding request, click Continue.

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