Donations and Grants

client_id

referrer_url

Requesting Party's Country*

Requesting Party's Name*

Requesting Party's Name in Local Language (if different from above)

Requesting Party's Address*

Requesting Party's Type*

If you selected "Other" above, please describe

Is Requesting Party a private or a public entity?*

PrivatePublic

Is/was/will Requesting Party be involved in any tender processes currently or over the past/next six (6) months?*

YesNo

If you answered "Yes" above, please provide further details

Requesting Party's Tax ID

Requesting Party's Website (if applicable)

Requesting Party would like to apply for a

Research GrantEducational GrantCharitable / Indigent Care Donation

To which therapeutic area does your application relate to?*

CardiopulmonaryNeuromodulationAdvanced Circulatory Support

If you have selected "Neuromodulation" above, please specify*

EpilepsyDepressionObstructive Sleep Apnea

If you have selected "Epilepsy" above, please confirm whether this is an indigent care request for Vagus Nerve Stimulation (“VNS”) - also known as VNS Therapy Access Program or “VTAP”:*

Yes, this is a VTAP applicationNo, this is NOT a VTAP application

Full name of the person submitting this application on behalf of Requesting Party and who will be the primary point of contact for LivaNova*

Relationship of the above-mentioned person with the Requesting Party (i.e. position / role)*

Contact email address*

Contact phone number

Requesting Party's W-9 form (US only)

Please upload your support request letter here. This should be on your organization's letterhead, dated and signed by someone with the appropriate authority to sign-off the request*

Please download the LivaNova Research Grant Form, fill it out and upload the completed form here*

Please download the LivaNova Research Grant Form

Please download the LivaNova Educational Grant Form, fill it out and upload the completed form here*

Please download the LivaNova Educational Grant Form

Please download the LivaNova Charitable Donation Form, fill it out and upload the completed form here*

Please download the LivaNova Charitable Donation Form

Please upload a no charge Purchase Order, including shipping instructions for the hospital*

If you have additional documentation you'd like to share with LivaNova, please attach it here

If your application involves the donation or loan of LivaNova products, please download the Product Request Form, fill it out and upload the completed form here

Please download the Product Request Form

Submission Date*

Please note: if you do NOT receive a "Thank You" email after submitting your application, this means your application submission failed. If this happens, please try again. If the issue persists, please email donationsANDgrants@livanova.com.

Please note: if you do NOT receive a "Thank You" email after submitting your application, this means your application submission failed. If this happens, please try again. If the issue persists, please email LIFE@livanova.com (VTAP applicants should email: NM.VNSTherapyAccessProgram@livanova.com).