Neurovascular Donation Request Forms

** It is important that you read the details under the application before you submit your application.**

Charitable Monetary

For charitable fundraising requests related to disease states treated by our therapies. The recipient, except in rare instances, must be a tax-exempt charity. It is important that detailed information about what the proceeds are for specifically are provided in the application. If you do not provide detailed information it will result in delay of the request being reviewed. Required documents to upload in the application are: Detailed information regarding the proceeds, detailed budget, and W9.

Healthcare Education Grant with CME/CEU credits

To support third-party scientific meetings and conferences, related to our approved therapies and related disease states. This type of meeting or conference may be sponsored by either a for-profit or a non-profit organization. Typical sponsors include professional societies, universities, hospitals and CME providers. The event must issue CME/CEU credits. Required documents to upload in the application are: Detailed agenda showing topics, detailed budget, and W9. If you do not provide detailed information regarding your meeting it will result in delay of the request being reviewed.

Healthcare Education Grant without CME/CEU credits

To support meetings and conferences and public education programs, related to disease states treated by our therapies. This type of meeting or conference may be sponsored by either a for-profit or a non-profit organization. Typical sponsors include professional societies, universities, hospitals and CME providers. Designed for events that do not issue CME/CEU credits. If there are levels of sponsorship available please provide the level information with details on what each level provides. Required documents to upload in the application are: Detailed agenda with topics, detailed budget, and W9.

Exhibit Fee Only Requests

This selection is for requests where there is opportunity to only exhibit at a conference or other meeting venue. Please provide all levels of exhibit options available. If you have multiple levels of exhibit opportunities please upload that information. Required documents to upload in the application are: Detailed agenda, detailed budget, and W9.

Fellowships

To partially subsidize accredited fellowship programs by funding fellows’ salaries and educational activities related to disease states treated by our therapies. The recipient, except in rare instances, must be a tax-exempt charity.

Neurovascular Patient Assistance Request

Application for product donation requests in the United States. Product donations may be provided for the sole benefit of indigent patients when customers agree to provide their services and facilities at no charge to the patients. Please provide details of the procedure you will be performing on the indigent patient application along with requested product. You will be required to fill out and sign two certifications: Surgeon Certification of Free Health Care, and Hospital Representative Certification of Free Health Care. You can find the certifications here: Additional Documents for Donation Requests.

Neurovascular Charitable Mission Product Request

Application for product requests for mission trips outside the United States. Requests must be submitted at least 8 weeks prior to the mission trip date. Product donations may be provided for the sole benefit of indigent patients when customers agree to provide their services and facilities at no charge to the patients. You are required to fill out a certification: Certificate of Free Health Care. You can find the certifications here: Additional Documents for Donation Requests.

Additional Documents for Donation Requests

Find printable copies of Medtronic templates and certification statements i.e. Product Donation Certifications. If the required documents are not uploaded in the application you will be unable to submit the application.

Non-Patient Use Product Donation

This selection is for product donations to organizations for non-patient use. Please provide detailed information about the request and what the product will be used for.

Internal Fundraiser Ticket Request

(For internal use only)
This selection is for employees or distributor sales representatives to request approval to purchase individual tickets at a charitable fundraiser. Please be sure to have the tax ID number for the organization as this is needed to fill out the application. The recipient must be a tax-exempt charity. Please contact Compliance with questions.