Clinical Support Request Application

Thank you for your interest in requesting support from Applied Medical. This interactive form allows organizations to submit a formal request for support in the form of a donation, grant, or clinical clinical education course.

As a new generation medical device company, Applied Medical is committed to making a meaningful difference in healthcare globally. Subsequently, we are proud to partner with organizations that are similarly focused on science and advancing clinical outcomes.

Please submit your request for support at least 60 days prior to your deadline. Your application will be evaluated by our Clinical Support Committee and a response will be provided within 30 days of your submission.

For more information, please email

Please note items with a red * are required fields.

Type of Request*


Type of Organization *

Surgical society

Non-profit organization

Teaching hospital
Accredited medical school

Hospital or medical center


Institution/Group Information

Address line 2:


Primary Contact

Organization Details

Please provide background information about your organization that includes the size, impact, goals, etc.

Event Information

Event date(s):

Event 1:

Yes No
Yes No

Yes No

Request Details


Please provide a description of your event and explain the specific purpose of your request to Applied Medical.

Yes No

Please Submit these documents with your application

  • W-9
  • Letter of request
  • Program agenda/curriculum (including objectives, topics, and planned speakers)
  • Meeting budget (including complete program expenses)
  • Letter of agreement
    (If you do not have one, check here, and one will be provided)