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Privacy Notice

FormAssembly

This Privacy Notice was last changed on October 31, 2018.

You are encouraged to read the Philips Global Privacy Notice, which applies to the personal data of individuals that is collected or used by Koninklijke Philips N.V. or its affiliates or subsidiaries (Philips).

This Privacy Notice applies to personal data collected and/or processed by the FormAssembly application (“App”). This is a notice of our Privacy practices; this is not a contract or agreement.

What Personal Data are collected and for which Purposes

FormAssembly provides the online form service to allow for investigator-initiated research applications and financial grant requests to be submitted to our internal teams via our website. The App uses data collected or processed in the form. We collect your personal data as a part of the investigator-initiated research application, the financial grant request, and for saving in-progress forms and other purposes described below.

The App makes use of analytics technology to identify which content fields provided within the App are filled out, to track your usage of the App and to improve your App experience. We also make use of this data to ensure that the App functions properly.

We use cookies, tags or similar technologies to operate, provide, improve, understand, and customize our Services. Cookies, or similar technologies, collect information about the surfing behavior of visitors, such as how often content is visited and sections of the App not used or most abandoned. This data provides information to make the structure, navigation and content of the App as user-friendly as possible. Examples include:

a. to track of the number of visitors to various pages of the form or features of the App

b. to track of the length of time that each visitor spends on certain aspects of the form

c. form improvement and/or optimization such as abandonments or even errors

With whom are Personal Data shared?

Philips may disclose your personal data to third party service providers, business partners, or other third parties in accordance with this Privacy Notice and/or applicable law.

Service Providers

We work with third-party service providers to help us operate, provide, improve, understand, customize, support, and market our Services.

We may share your personal data with the following service providers:

IT and Cloud Providers

These service providers deliver the necessary hardware, software, networking, storage, transactional services and/or related technology required to run the App or provide the Services.

Philips requires its service providers to provide an adequate level of protection to your personal data similar to the level that we provide. We require our service providers to process your personal data only in accordance with our instructions and only for the specific purposes mentioned above, to have access to the minimum amount of data they need to deliver a specific service, and to protect the security of your personal data.

Other third parties

Philips may also work with third parties who process your personal data for their own purposes. Please read their privacy notices carefully as they inform you about their privacy practices, including what type of personal data they collect, as well as how they use, process and protect it.

If Philips shares personal data with a third party that uses your personal data for their own purposes, Philips will inform you and/or obtain your consent in accordance with applicable laws before we share your personal data.

Philips sometimes sells a business or a part of a business to another company. Such a transfer of ownership could include the transfer of your personal data directly related to that business to the purchasing company. All of our rights and obligations under our Privacy Notice are freely assignable by Philips to any of our affiliates in connection with a merger, acquisition, restructuring, sale of assets, by operation of law or otherwise.

How long do we keep your data?

We will retain your personal data for as long as needed or permitted in light of the purpose(s) for which the data is collected. The criteria we use to determine our retention periods include: (i) the length of time you use the App; (ii) whether there is a legal obligation to which we are subject; or (iii) whether retention is advisable in light of our legal position (such as in regard to applicable statutes of limitations, litigation or regulatory investigations).

Choices and rights

Please refer to the chapter ‘Your rights and choices available to you’ in the Philips Global Privacy Notice if you would like to submit a request to access, rectify, erase, restrict or object to the processing of Personal Data that you have previously provided to us, or if you would like to submit a request to receive an electronic copy of your Personal Data for purposes of transmitting it to another company (to the extent this right to data portability is provided to you by applicable law).

Local specific information: Your California Privacy Rights (US Only)

California Civil Code Section 1798.83 permits our customers who are California residents to request and obtain from us once a year, free of charge, information about the personal information (if any) we disclosed to third parties for direct marketing purposes in the preceding calendar year. If applicable, this information would include a list of the categories of personal information that was shared and the names and addresses of all third parties with whom we shared information in the immediately preceding calendar year. If you are a California resident and would like to make such a request, please visit our privacy website: http://www.philips.com/a-w/privacy/questions-and-feedback.html

Changes to this Privacy Notice

The services that Philips provides may change from time to time without prior notice to you. For this reason, we reserve the right to change or add to this Privacy Notice at any time.

We encourage you to check back often to review the latest version. Any new Privacy Notice will be effective upon posting. If you do not agree with the revised notice, you may cancel your account. By continuing to access or make us of our services after a new Privacy Notice becomes effective, you acknowledge that you have been informed of the revised Privacy Notice.

Contact Us

If you have any questions about this Privacy Notice or about the way Philips uses your Personal Data, please contact our Data Protection Officer via our contact form. Alternatively, you have the right to lodge a complaint with a supervisory authority or law enforcement competent for your country, state or region.

Koninklijke Philips N.V.
High Tech Campus 5
5656AE, Eindhoven
The Netherlands

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Financial and In-kind Support for Third Party Educational Programs - Application Request

* Denotes a field that must be completed: Enter "N/A" or "$0" if applicable

Type of Funding

Applicant/Entity Details

Name of Applicant

Entity receiving the financial support

Street Address

City

State/Province

Zip/Postal Code

Entity Country

Is applicant a non-profit organization?

Is the entity owned or controlled by a physician (or family member of a physician) in a position to use or recommend Philips IGT products?

Does the entity employ or have a contractual relationship with a physician (or family member of a physician) in a position to use or recommend Philips IGT products?

Make Check Payable To

Is check payable to Applicant?

Attn To:

Tax ID (EIN)

Enter the Tax ID (EIN) of Country equivalent (i.e. VAT, CNPJ, etc.) of the Entity to which the check will be sent.

Send check to Applicant Address?

Send Check to...

Send Check to - Address

Send Check to - City

Send Check to - State/Province

Send Check to - Zip Code/Postal Code

Send Check to Country

Applicant Contact Person's Information

First Name

MI

Last Name

Phone Number

Contact Email

W8 / BEN #

Event Details

Event Title

Event Start Date

Event End Date

Is this a second or subsequent request for an event?

Describe if second or subseguent request for an event;

Event Location

Venue

Event Address

Event City

Event State/Event Province

Event Zip/Postal Code

Event Country

Additional Event Details

Reference to the Event Agenda

Expected Number of Healthcare Professionals Attending

Target Audience

(pick as many as applicable) Hold Cntrl down to select multiiple options.

Accreditation Statement

Educational Focus of Event

Is time set aside for recreational activity?

(e.g., golf, tennis, skiing, wine tasting tour)

Total Recreational Time Allotted

(Recreational activity between commencement and adjournment of meeting)

Will Philips IGT Funds be used to support recreational or entertainment activity?

(e.g., golf, tennis, skiing, wine tasting tour)

Yes, Philips IGT Funds will be used in support of recreation or entertainment explanation:

Amount of Funding Requested for:

Type of Funding

Exhibit or Booth Space Amount =

Please enter a single number value

Grant/General Support Amount =

(Sponsorship or Grant) Enter a single number value please.

Description:

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Upload Required Documentation:

**Please Note: ALL Documents in this section MUST be included for successful application submission

Letter of Request:

(Should have the event description on Applicant's Letterhead)

Full Educational Program Agenda

(Topics and times)

Payee's Signed IRS W-9 Form (Or International Equivalent)

Sponsorship Opportunities / Offerings

Upload Recommended Documentation:

IRS Tax Exempt Determination Letter

(if a US tax exempt entity)

PDF Format Requested

Event Budget

Exhibit Reservation Form / Exhibit Rules Information

Exhibit Layout

Certification:

This application for financial support is made for the sole purpose of offsetting the expense of legitimate educational activity, and is not related to or conditional on the inception or continuation of any business relationship with Philips IGT or any of its employees or affiliates.

I Agree