Passion for Innovation. Compassion for Patients.™

Daiichi Sankyo UK Ltd.

Grants and Donations Application form – Patient Organisations

Grants and Donations Application form – Patient Organisations

Section 1
Contact Details of Primary Contact
Section 2
Section 3

Detailed Description of the Programme to include the following information. Please attach any supporting materials.

There is no need to complete all the fields in this section. Complete only those that are relevant to the programme.

Section 4

If request for funding is in relation to a meeting provide cost of room hire, subsistence, travel, overnight accommodation, communication and materials associated with the event and honoraria (upload in section 7)

iv. Has request for funding in relation to this programme been requested from any other organisations? *
Section 5
Has your Organisation received any funding from Daiichi Sankyo UK in the last 3 years? *
Section 6

If you are requesting funding on behalf of a charitable organisation please provide the following documents with your application.

Section 7
Anti-Bribery Questionnaire

‘Bribery’ is defined as:

‘Giving someone a financial or another advantage to encourage that person to perform their functions or activities improperly or to reward that person for having already done so. So this could cover seeking to influence a decision-maker by giving some kind of extra benefit to that decision maker rather than by what can be legitimately be offered as part of a tender process.’
In order to prevent any unwitting engagement in behaviour which might raise the suspicion of bribery each application for a Grant of Donation must be accompanied by a completed ant-bribery assessment form.

Please read and act in accordance with the Anti-bribery Act – Click here

Please complete the following questions. Daiichi Sankyo will not be able to review your application for a Grant or Donation unless these are completed.

1. Are you aware of the Bribery Act of 2010? *
3. Has anyone employed by Daiichi-Sankyo, including third parties retained by Daiichi-Sankyo, offered any payments or gifts to you or your organisation that were dependent on a benefit in kind being given to Daiichi-Sankyo?
5. Does anyone in your Organisation make or influence decisions on any of the following in relation to Daiichi Sankyo products? Please respond with a YES or a NO.
5.1. Approval of Product Licenses
5.2. Health Technology Appraisals
5.3. Inclusion into Formularies, Guidelines or Protocols
6. If you responded or responded on behalf of anyone in your organisation with a YES to any of the question above please complete the following section