|*The request is for:|
|*Organization Type (select one):|
(e.g. hospital, university, conference center, hotel etc)
|*Is this Program accredited:|
Please attach the following documents
(i.e. on letterhead, dated & signed)
(i.e. pamphlets, brochures, invitations, etc.)
(e.g., Bank Name, Account Number, SWIFT/IBAN code, etc.)
|*Has your organization received support in the form of a donation or grant from LivaNova in the past?:|
If any such actual or potential conflict of interest arises you shall immediately inform the Company in writing of such conflict.
By submitting this application, I acknowledge and agree to the following:
- The information presented on this form is accurate, true and correct.
- I am acting under authorization of the organization requesting funding from LivaNova.
- I confirm that this request is not and will never be tied to the prescription or purchase of LivaNova products or services.