Product Donations for Humanitarian Aid Grant Application

Instructions

A product donation request cannot be reviewed until this Grant Application is completed in its entirety and all required documents have been submitted at least 60 days prior to the date the items need to be shipped.

Any questions regarding this Grant Application should be directed to Acumed’s Grants Committee at grants@acumed.net.

The Grant Application cannot be considered without the Product Description Proposal form completed and attached.

Contact Information

All notifications, questions, etc. regarding this Grant Application will be directed towards the Contact Person listed below.

Contact Person *

First

Last

Contact Person for this Grant Application

Contact Person's Title *

Contact Person's Organization *

Contact Person's Email Address *

Contact Person's Phone *

Nonprofit Organization Applicant Information

Nonprofit Organization Name *

The receiving organization of the product donation

Nonprofit Organization Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Nonprofit Organization Tax ID # *

Nonprofit Organization Website *

Requesting Surgeon(s) *

Under whose direction these products are being requested

Medical Mission Trip Information

PLEASE NOTE: Acumed will not provide a product donation for locations that are subject to a U.S. embargo or economic sanctions program.

Locations can be checked at:

Medical Mission Location *

Medical Mission Departure Date *

Medical Mission Return Date *

Date Products are Needed *

Request must be at least 60 days from the date this Grant Application is received for consideration

Number of Surgeries Planned *

Trip Purpose and Details: *

What type of products are you requesting? *

Please list products lines you have previously used *

If available, a comparable legacy line similar to what you have used may be considered for the donation

What type of procedures are you planning to use these products for? *

Name of Facility *

Location where surgeries will occur

Facility Address (location where surgeries will occur) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Facility Contact Person *

First

Last

(Contact Person at the Facility where surgeries will occur)

Facility Contact Person’s Title *

Facility Contact Person’s Email Address *

Faculty Contact Person’s Phone *

Shipping Information for Product Donation

PLEASE NOTE: US shipping address only.

Shipping Contact Person *

First

Last

Shipping Contact Person’s Email Address *

Shipping Contact Person’s Phone *

Shipping Address *

Address Line 1

Address Line 2

City

State

Zip Code

US shipping addresses only

Required Attachments

Requests cannot be considered without the attached documents. The following file formats are allowed: .pdf, .doc, .docx, rtf, odf

Product Description Proposal *

Click or drag a file to this area to upload.

Product Description Proposal Form

Nonprofit Organization’s W-9, 501(c)(3) tax-exempt IRS Determination Letter, or W-8BEN-E *

Click or drag a file to this area to upload.

For Nonprofit Organizations located outside of the United States that do not have a W-9 or 501(c)(3) tax-exempt IRS Determination Letter, please provide a W-8BEN-E which can be downloaded from the United States Department of Treasury Internal Revenue Service website.

Letter of Request on Nonprofit Organization Letterhead *

Click or drag a file to this area to upload.

Letter of request must include the following statements: (a) The implanting physician(s) requesting the product donation are affiliated with a nonprofit organization that engages in humanitarian aid and medical missions to provide indigent care. (Humanitarian Aid Mission); (b) The requested product donation is exclusively for the benefit of indigent patients for non‐profit, charitable, and humanitarian aid purposes only. (Indigent Care); (c) Neither the implanting physician(s), Nonprofit Organization Applicant, their agents, nor affiliates will resell, or charge patients for the donated product(s). (No Device Charge); (d) The implanting physician(s) and staff are donating their services to implant the device. (No Surgery Charge); (e) The hospital the surgeries will occur is donating their services and facility to implant the device. (No Hospital Charge)

Additional Attachment (optional)

Click or drag a file to this area to upload.

Certifications

This Certification is intended to comply with the laws and regulations that apply to the subject matter of this request and the relationship between donors and donees including but not limited to the federal Anti-Kickback Statute (42 U.S.C. §1320a-7b) and state anti-kickback laws and regulations. Acumed reserves the right to modify this Certification for such reasons as Acumed deems appropriate to ensure compliance with state and federal laws and regulations.

Submitter's Name *

First

Last

(Individual submitting this Grant Application)

Submitters's Title *

Submitter’s Organization *

Date *

I, the Submitter of this Grant Application, certify that to the best of my knowledge all the following statements are true with respect to the submission of this Grant Application:

I have the requisite authority to submit this Grant Application on behalf of the receiving organization.
All information provided in this Grant Application and Required Attachments are true and accurate.
The requested products: (a) are exclusively for the benefit of indigent patients for non‐profit, charitable, and humanitarian aid purposes only; and (b) will not be the subject of any sale, lease, trade, barter, or other transfer in exchange for money, property or services by the receiving organization, its personnel, or me to individuals, or entities in the United States, or other countries.
The receiving organization, its personnel, and/or I have obtained: (a) any necessary import license for the requested products from the destination country; and (b) the necessary health authorization (if applicable) from the destination country.
The receiving organization, its personnel, and I have not, implicitly or explicitly, solicited the requested donation in exchange for an agreement to purchase, use, order, or recommend Acumed products.

Note: The submission of this Grant Application does not guarantee approval of this Grant Application, and if approved by Acumed, Acumed may in its sole discretion: (a) approve a product donation of less than what has been requested; (b) approve a product donation of a comparable legacy line similar to what has been requested; and (c) condition approval upon receipt of a fully executed donation agreement between Acumed and the receiving organization.