OptiMotion Implants, LLC | Fellowship Grant Program

Fellowship Grant Application

Instructions

Complete all sections and attach the requested materials. Submission of an application does not guarantee funding. Grant awards are made based on objective criteria and are not tied to past, current, or expected purchases or use of OptiMotion products.

1. Applicant Information

Legal name of applicant organization(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary contact name(Required)

Primary contact title(Required)

Primary contact email(Required)

Primary contact phone(Required)

Tax ID / EIN(Required)

Type of organization(Required)

Is applicant affiliated with any physician owner, director, officer, employee, or consultant of OptiMotion?(Required)

Yes

No

If yes, please describe the affiliation

2. Fellowship Program Information

Name of fellowship program(Required)

Specialty / focus area(Required)

Program start date(Required)

Program end date(Required)

Number of fellows(Required)

Program Director(Required)

Program Location(s)(Required)

Will fellows perform clinical services?(Required)

Yes

No

Will fellows be employees of applicant?(Required)

Yes

No

If fellows will perform clinical services, please describe

If fellows are NOT employees of applicant, explain the relationship

3. Educational Purpose and Program Description

Describe the educational and training purpose of the fellowship program(Required)

Describe the curriculum, supervision, training activities, and expected educational outcomes(Required)

4. Requested Grant Amount and Budget

Attach a detailed budget using the Recipient Budget Template.

Requested Grant Amount and Budget(Required)

Fellow Salary

Amount ($)

Justification

Benefits

Amount ($)

Justification

Education / Training Expenses

Amount ($)

Justification

Conference / Course Expenses

Amount ($)

Justification

Program Administration

Amount ($)

Justification

Other

Amount ($)

Justification

Budget total ($)

5. Required Certifications

certifications

Applicant will select the fellows independently and without OptiMotion involvement.

Applicant will employ, supervise, and be responsible for the fellows, unless otherwise described in the application.

The grant is not being requested, offered, or accepted in exchange for the purchase, use, recommendation, referral, or ordering of OptiMotion products.

The grant will not be conditioned on any past, current, or expected OptiMotion product utilization.

Fellow compensation will be commercially reasonable and, where applicable, consistent with fair market value.

Fellow compensation will not be determined in a manner that takes into account the volume or value of referrals or product usage.

Applicant will use grant funds only for approved fellowship program expenses.

Applicant will provide information reasonably requested by OptiMotion to assess and satisfy Open Payments/Sunshine Act reporting obligations.

Applicant will provide expense reports, certifications, and supporting documentation if requested.