Amgen Healthcare Donations | Amgen Canada

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In order for your request to be reviewed by Amgen Canada, please complete all of the fields within the form below. The request will not be submitted if there are missing fields. Please provide as much detail as possible where requested.

Information with an asterisk (*) is mandatory

Detailed Program Description
What is the title of your event, program or project?*
Please attach your written letter of request (including date and signature).*
Please provide the full legal name of the requesting institution / organization*
Please provide the name of primary point of contact.
Title*
First Name*
Last Name *
Please provide related contact information:
Phone*
E-mail*
What is the mission or purpose of the requesting non-healthcare institution / organization?*

What are the start and end dates of the event, program or project?
Start date *
End date*
Please provide a full description & objectives purpose of the event, program or project.*

What is the target audience for the program/event?*
Are there any event, program or project related materials available? (e.g. draft agenda, a flyer / brochure, or website information etc.)
Yes   No
If yes, enter website if available, or attach supporting documentation:
Supporting documentation:
If no, please provide related details:


Detailed Donation Requirements

What is the total amount (in CDN$) requested from Amgen?*
What is the total program / event budget (in CDN$)?*
Will it be acceptable if Amgen provides a donation for an amount less than requested above?*
Yes   No
If no, please comment:
Please provide details on how the funds will be used.*

Will the program/event be multi-sponsored?*
Yes   No


Payee Information

Please provide the full legal name of the requesting institution / organization*
Please provide the full legal address of the requesting institution / organization
Address1*
Address2
City*
Province*
Postal Code*
Is the requesting institution / organization a not-for-profit or tax-exempt organization? *
Yes   No
If yes, enter the related tax ID:*