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



Please use the form below to apply for all charitable monetary donations, healthcare education grants, or Sorin product donations. All requests should be received six (6) weeks prior to the date the donation or grant is needed in order to ensure time for review and processing.

We ask that your request is specific to one (1) of Sorin's Business Units: cardiopulmonary, heart valves, or cardiac rhythm management. In the event you would like to make the request to more than one (1) of Sorin's Business Units, please submit individual requests for each desired business unit in order to ensure proper processing and review.

If you have any questions or problems, please send an email to sorin.donations@sorin.com or call 303-467-6528.

1. A list of your organizations board members and their affiliations
2. A detailed budget pertaining to the program (If Applicable)
3. A completed W-9
4. An overview of all available sponsorship levels (if applicable)
5. A copy of the invitation, brochure and any other applicable documentation
Applications will be denied if all required documentation is not provided.
This request is for:
 Cardiopulmonary and Blood Management       Heart Valves       Cardiac Rhythm Management     
 
Type of Request:

If your request is solely for Sorin to market or exhibit at a conference or other meeting venue, you do not need to complete this application. Please contact Sorin Compliance at 303-467-6557 or soringroupethics@sorin.com.
 Educational Grant       Charitable Donation       Product Donation     
 
Is this request a combination of an educational grant and exhibit?*:   Yes      No
 
Organization name*: 
 
Organization Type (select one):  501c3 Non-profit       Other-non profit designation       For Profit     
 
Contact Name *: Contact email Address*:
 
Contact Address *: Contact phone number*:
 
Website: Organization Tax ID*:
 
Is your organization a health care professional or affiliated with a health care professional (e.g. physician, hospital)?*:
 Yes       No
 
Is anyone in your organization licensed or registered within the state of Massachusetts or Vermont?*:
 Yes       No
 
What is your organization's mission (300 words or less):
 
Provide a history of past funding support from Sorin, including the program and amount provided.:
 
Provide a list of Sorin employees affiliated with your organizations and the relationship
(e.g. sales rep,volunteer, etc.).:

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.
  • Requestor represents and warrants that any donation granted is unrelated to referrals of Sorin products, and will have no effect on future referrals of Sorin products.
    		•
     
      I agree   I do not agree
    Signature: Date:

    You must receive a confirmation email acknowledging submission of your request or your request has not been submitted.