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Instructions for Completing Charitable Donation Request Forms This

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					                                                                         MSB Assigned Tracking Number: _______________

                                                             Charitable Mission Product Donation
            Spinal and Biologics                                        Request Form

            Instructions for Completing Charitable Donation Request Forms
This Medtronic Spinal and Biologics (MSB) Charitable Donation Request Form is formatted with MicroSoft’s form tool. To
complete the request form:

     Move to each field that needs to be completed by using the Tab button or by moving your curser to the next field.
     If the field is a box like “ ” then just click on the appropriate box to place an “x” in the box.
     If the field is a gray text area (it is empty white space in a printed version of the form), simply start typing in the
      requested information.
     If you need to unlock this form to add information that does not have a box or text field: (1) select “View” on the top
      menu bar of your computer, (2) select “Toolbars,” (3) select the “Forms” toolbar. Once the toolbar is added, click on
      the icon that looks like a padlock so it is no longer highlighted. You can then type anywhere on this document. If you
      click on the padlock again, you may lose the information you entered in a box or text field – so do not unlock
      this document until you have completed all of the form fields and then do not re-lock it.

In order to assure readability, MSB prefers that all request forms be typed rather than handwritten.

If you have a paper version of the request form and need an electronic version, send an email to MSB’s Charitable Donation
Manager at MSBCharitableContributions@medtronic.com and ask for an electronic version of a Charitable Donation
Request Form. Identify which of the following request forms you want to request:

             Charitable Mission Products                Fundraiser Event
             Fellowship                                 Patient Assistance
             Monetary

Submit the form according to the directions on the form. To avoid any delays in reviewing your request, please be
sure to complete the request form and provide all of the requested information and documents.

If you have any questions about the request form or MSB’s charitable donation program and practices, send an email to
MSBCharitableContributions@medtronic.com.


                               Medtronic Spinal and Biologics Charitable Donation Policy
 Medtronic Spinal and Biologics makes charitable donations that (1) benefit society and promote better health, (2)
 demonstrate good corporate citizenship, or (3) serve a genuine educational function. It makes donations only to tax-
 exempt charitable organizations, or, in rare instances, to individuals engaged in a genuine charitable mission. Recipient
 selection for donations is made on the basis of objective review criteria and not based on whether the Requester or
 Recipient orders, uses, purchases, or recommends MSB products. Donation decisions comply with the AdvaMed Code of
 Ethics and Medtronic’s U.S. Business Conduct Standards.



Charitable Mission Product Donation Request Form           Page 1 of 7                                                  Ver. 2.1
                                                                     Charitable Mission Product Donation
                                                                                Request Form
            Spinal and Biologics

                                                 Submission Information and Instructions
                                                        Donation Request Documentation
MSB requires this charitable donation request form (including any attachments applicable to this request) to be completed and
submitted with all specified supporting documentation before it will review your request. Please:
     1. Read through this form to understand the information and documents necessary for submission.
     2. Note that MSB sales personnel may not complete this form for you (except for product donation lists) or commit MSB
        to making a donation.
     3. Complete and sign the form (including all applicable attachments) and gather all required supporting documentation.
     4. Submit the completed and signed request form and all required supporting documents by fax or mail to MSB’s Charitable
        Donations Manager at:

                     MSB Charitable Donations Manager
                     Medtronic Spinal and Biologics
                     1800 Pyramid Place
                     Memphis, TN 38132
                     Fax: (901) 344-1576
                     Email: MSBCharitableContributions@medtronic.com
                                                   Charitable Donation Request Review Process
     1. MSB’s Charitable Donations Manager, not a Sales Representative, will be your point of contact for any questions you may
        have. MSB’s Charitable Donations Manager will acknowledge receipt of your request and notify you if any additional
        information is necessary.
     2. All donation requests are reviewed and decided on by designated staff or a MSB Charitable Donations Committee.
     3. Allow 6-8 weeks for MSB to review your request, except for requests for research funding, which can take 8-12 weeks. The
        Charitable Donations Manager will notify you of MSB’s decision.
     4. Starting May 1, 2008, Medtronic, Inc. will post donation information on its website at www.Medtronic.com/donations. Any
        donation requested on or after that date will, if funded, be included in Medtronic’s Donations Registry; donations made prior to
        May 1, 2008 and donations committed to before that date, regardless of when they are funded, will not be included in
        Medtronic’s Donations Registry. Information regarding the Medtronic Foundation’s donations is already publicly available at
        www.Medtronic.com/foundation.
MSB requires a signed Charitable Donation Agreement before certain types of donations are made.



                                  General Information Regarding Requester and Recipient
Name of Person Completing                                                 Requester’s Title and
Request Form (“Requester”)                                                Position with Recipient
Requester’s Phone Number                                                  Requester’s Email




Charitable Mission Product Charitable Donation                     Page 2 of 7                                                   Ver. 2.1
Request Form
                                                                        Charitable Mission Product Donation
                                                                                   Request Form
            Spinal and Biologics

                                  General Information Regarding Requester and Recipient
Requester’s Address
Recipient’s1 Full Legal Name                                                   Recipient’s Address
Recipient’s Phone Number                                                       Recipient’s Fax Number
Recipient’s Email Address                                                      Recipient’s Web Site
Recipient’s Address
Recipient’s Tax ID Number2
                                                 501(c)(3)                                           501(c)(6)
Recipient’s Tax Exempt
Status                                        Charitable mission not organized through
                                                                                                     Other (Describe)
                                         tax exempt organization
                                                                       Name(s) of Recipient’s MSB
Donation Due Date
                                                                       Sales Representative(s)
Will any of the donation be                      Yes    If yes, describe how
used to fund lobbying                                   much and the
activities?                                      No     lobbying activities



                                        Charitable Mission Product Donation Information
Name of Physician                                                         Charitable Mission
                                                                                                                 to
Leading the Mission                                                       Dates
Hospital(s) to be used for the surgeries
Countries in which donated products
will be used
Describe the patients and type of health
care services to be provided 3
Expected number of patients
Will all donated products be provided free of charge to an indigent population?                                   Yes                 No
If no, please describe what the charges will
be or how they will be determined

1 The “Recipient” is the person or organization who will ultimately receive the donation. Except for Charitable Mission or Pat ient Assistance Product
Donations that are not organized through a charitable foundation, the identified Recipient must be a tax-exempt charitable organization. This
entry should match the name on the IRS tax-exemption determination letter.
2 This should match the Tax ID number on the IRS tax-exemption determination letter.
3 Biologic products are generally not available for charitable missions because they are not approved in most countries and/or strict shipping and

temperature requirements that cannot be met.
Charitable Mission Product Charitable Donation                        Page 3 of 7                                                               Ver. 2.1
Request Form
                                                                    Charitable Mission Product Donation
                                                                               Request Form
            Spinal and Biologics

                                        Charitable Mission Product Donation Information
Will all health care professionals using the products and the facilities at which they are
                                                                                                       Yes                No
used be providing their health care services free of charge?
If no, describe how and when the health
care professionals or facilities will be paid.

Date products must be on site for use
                                                                      MSB needs at least 6-8 weeks to arrange
                                                                      product donations to foreign countries.

Planned last day of mission
                                                                      Unused products must be returned within one
                                                                      week after last day of mission trip
                                                 Name

Name, address, phone number, and                 Address (No P.O.
email address for location to which              Boxes)
products should be shipped.                      Phone Number(s)
                                                 Email Address

Name, address, phone number and                  Name
email address for contact at destination         Address
in the event of problems. (If it is the
same as the above, state “Same” for              Phone Number(s)
the Name field.)                                 Email Address




MSB’s Donations for Past 5 Years



                                          Additional Product Supporting Documentation
In addition to the “Supporting Documentation Required for All Requests,” also provide the following:
     1. Completed product listings describing each of the products needed for the charitable mission. The product listings should be
        completed by the local MSB sales representative for the physician leading the mission to ensure they include all required
        products and the necessary product information.
     2. If the donation is to support an individual engaged in a genuine charitable mission that is not tax-exempt, a copy of the
        individual’s curriculum vitae or resume.



Charitable Mission Product Charitable Donation                   Page 4 of 7                                                        Ver. 2.1
Request Form
                                                                 Charitable Mission Product Donation
                                                                            Request Form
            Spinal and Biologics

                           Control of and Required Return of Unused MSB Products
The physician leading the charitable mission is responsible for maintaining control over any MSB Products
donated to this charitable mission from the time the MSB Products arrive at the charitable mission location until
the unused MSB Products are shipped back to MSB, using shipping vendors or systems acceptable to MSB.
All unused MSB products must be returned to MSB. They may not be retained for any use other than this specific
charitable mission. If the donation request is approved, MSB’s Charitable Donations Manager will provide
information regarding the return of unused products. Failure to return unused MSB Products may cause denial of
future charitable mission requests.
The physician leading the charitable mission is relieved of this obligation if an MSB representative is onsite during
the charitable mission and the MSB representative assumes responsibility for receiving and returning the MSB
Products.



                                                 Certification of Free Health Care
I, the undersigned, certify that to the best of my knowledge, the treating physician(s), any other health care provider(s), and
the facility(ies) at which care will be provided during this charitable mission will not charge the patients who receive the
donated products, or any other third party, for any services or supplies related to the surgeries described in this request
form.
I understand that if there are any such charges, including nominal charges based on ability to pay, that I must promptly
notify Medtronic Spinal and Biologics, that Medtronic Spinal and Biologics will determine whether the charitable mission
qualifies under its policies and, if not, that an exception to its policies will be required before this donation can be approved.


Requester’s Signature                                                             Date




                                    Supporting Documentation Required for All Requests
The following documentation must accompany all requests for Charitable Donations:
     1. If the Recipient is a tax-exempt organization, a copy of the Recipient’s IRS tax-exemption determination letter.
     2. A detailed budget identifying all anticipated costs and donations and other revenues for the proposed activity, event or project
        (or other reasonable evidence that the amount of this donation request is not in excess of the anticipated net costs of the
        proposed charitable activity, event or project).
     3. Any other additional documentation identified in this request form.




Charitable Mission Product Charitable Donation                 Page 5 of 7                                                        Ver. 2.1
Request Form
                                                                    Charitable Mission Product Donation
                                                                               Request Form
            Spinal and Biologics

                                                     Certificate of Compliance
I, the undersigned, certify that to the best of my knowledge, the following statements are true with respect to this donation request:
     1. The Recipient, its personnel, and I did not, implicitly or explicitly, solicit the requested donation in return for an agreement to
        purchase, use, order, or recommend MSB products.
     2. No MSB representative implicitly or explicitly offered a donation to induce the Recipient, its personnel, or me to purchase, use,
        order, or recommend MSB products or to reward prior purchases, uses, orders, or recommendations of MSB products.
     3. The requested donation would not result in more than an incidental private benefit to a surgeon who uses, orders, or
        recommends MSB products (e.g., a surgeon who will act as a fellow’s supervisor) or another individual.
     4. All of the information included on and documentation attached to this request form by the Requester and/or Recipient is
        accurate.
If you have any questions about this Certificate or if you cannot complete the Certificate because the information is not
accurate, please notify MSB’s Compliance Officer by calling 901.399.2672 or sending an email to
MSBCompliance@medtronic.com. MSB’s Compliance Officer will work with you to help avoid any violation of federal or state
laws, including applicable anti-kickback laws.



Requester’s Signature                                                                   Date




Charitable Mission Product Charitable Donation                    Page 6 of 7                                                          Ver. 2.1
Request Form
                                                                               MSB Assigned Tracking Number: _______________

                                                                   Charitable Mission Product Donation
           Spinal and Biologics                                               Request Form


                                         Medtronic Spinal and Biologics
                                         Product Donation Request List
                                (To be Completed by a MSB Sales Representative)
                                                       Surgery/Order Number:

                                                                                                                       Product Division
System/Set Type or




                                                                                                                                     Interbody
                                                                                                           Biologics




                                                                                                                                                  Thoraco-
                                                                                                                          Cervical
                                                   Product Description                        # of Units




                                                                                                                                                   lumbar
   Item Number




Charitable Mission Product Donation Request Form                 Page 7 of 7                                                                     Ver. 2.1

				
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