Sorin Group USA -

Application for Educational, Research, and Charitable Donations from Sorin Group

Please complete all relevant fields and click the button at the bottom of the page or fax to the Sorin Group Charitable Donations Committee at 866.808.7193

To the best of my knowledge the information presented on this form is accurate, and I have included relevant information pertaining to my organization's status as a non-profit including a tax identification number:

I agree I do not agree

This request is for:

Cardiopulmonary and Blood Management

Heart Valves

Cardiac Rhythm Management

PART A (PLEASE COMPLETE ALL FIELDS)

ORGANIZATION TYPE(circle one):	501c3 Non-profit Other-non profit designation For Profit
Organization *:
Contact Person *:
Phone *:
Email Address*:
Organization Website:
Fax:
Your contact at Sorin Group:

PART B (PLEASE COMPLETE B-1 Or B2)

B1-For support related to Educational and Scientific Conferences:

Program Name:
Program Objective:
Program Date:
Program location:
Donation Amount:
Target Audience:
Anticipated number of attendees:
If entity is for-profit, please identify accrediting CME or CEU organization:
Please indicate type of acknowledgement Sorin will receive :	Program mention Exhibit space Banner or tabletop Advertisement
Other:
Please indicate what, if any, advertisement materials are required by Sorin and anticipated dead line :

B2-For Product-Related Donation:

Product donation (include device number/model and quantity Requested):
Requesting Institution :
Request Contact Person Name :
Shipping Address :
Shipping date :
Please include any accessories to device requested :
Please indicate intended usage of donated product :

Part C (PLEASE COMPLETE ALL FIELDS)

If approved, "Ship To" Address*:
Entity Name*:
Tax ID #*:
Address*:
City*:
State*:
Zip*:

Part D (DOCUMENT UPLOAD)

If you would like to submit additional information, please fax it to 866.808.7193
Upload your written request stating the requested donation amount and a description of how the donation will be used :*
Upload a copy of an official program, agenda and exhibitor registration form for conference request :*
If applicable, upload a completed W-9 form :
If applicable, upload a letter verifying status as a not-for-profit entity: