Apply for Donation | Amgen Canada

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You are now leaving the Amgen Canada website. Please note that the information you are about to view may not comply with Canadian regulatory requirements. Marketing authorizations and availability of products may differ between Canada and other countries.

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 and institution/organization information:
Phone*
E-mail*
Fax *
Website
What is the mission or purpose of the requesting healthcare institution / organization?*

What are the start and end dates of the event, program or project?
Start date*
End date*
*Please note that if your event start date is within the next 90 days, it may not be reviewed in time of the event.
Please provide a full description & objectives / purpose of the event, program or project.*

What is the target audience for the program/event?*

Detailed Donation Requirements

What is the total amount (in CDN$) requested from Amgen?*
Please provide details on how the funds will be used.*

Payee Information

Please provide the full legal name of the requesting institution / organization*
If different from the full legal name of the institution/organization, please provide the payee name for the donation cheque (i.e. institution or 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, please provide the Charitable Registration Number:*
Note: upon submitting your request you should receive an email confirmation from Amgen. If you do not receive one, please email CanadaHCCDonations@amgen.com to confirm receipt of your request.