Charitable Contribution Request Form

Charitable Contribution Request Form

DESCRIPTION OF ACTIVITY
Activity Synopsis (Description and Purpose)
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REQUESTING ORGANIZATIONINFORMATION
Organization Legal Name:
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Tax ID#:
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Contact Name:
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OrganizationType:
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WebsiteURL:
Click or tap here to enter text. / Proportion of organization’s Annual funding coming from Astellas.:Click or tap here to enter text.
OVERVIEW
Area ofInterest:
Click or tap here to enter text. / Request Type (e.g. funds requested, other):Click or tap here to enter text.entertext.
Activity Start Date:Click or tap here to enter text. / Activity End Date: Click or tap here to enter text.
BUDGETDETAILS
RequestedAmount:
Click or tap here to enter text. / Total BudgetAmount for the Activity (if different from the amount requested):
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Approximate percentage of organization totalannual budget that this request wouldrepresent:
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Any additional information relating to the request:
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Please provide details of any other confirmed or potential partners/supporters in relation to this request:
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Review and approval (to be completed by Astellas personnel)

Request number: Click or tap here to enter text. / Does the request meet criteria of the SOP?
Yes: ☐ / No :☐
Date reviewed: Click or tap here to enter text. / Outcome of review:
Approved: ☐ / Approved subject to amends (specify below): ☐ / Further Info required (specify below): ☐ / Declined (specify below): ☐
Comments: Click or tap here to enter text.
Signatory 1
Forename: Click or tap here to enter text. / Surname: Click or tap here to enter text. / Signature: Click or tap here to enter text. / Date: Click or tap here to enter text.
Signatory 2
Forename: Click or tap here to enter text. / Surname: Click or tap here to enter text. / Signature: Click or tap here to enter text. / Date: Click or tap here to enter text.
Signatory 3
Forename: Click or tap here to enter text. / Surname: Click or tap here to enter text. / Signature: Click or tap here to enter text. / Date: Click or tap here to enter text.
Signatory 4
Forename: Click or tap here to enter text. / Surname: Click or tap here to enter text. / Signature: Click or tap here to enter text. / Date: Click or tap here to enter text.
Signatory 5
Forename: Click or tap here to enter text. / Surname: Click or tap here to enter text. / Signature: Click or tap here to enter text. / Date: Click or tap here to enter text.
ASTELLAS CONFIDENTIAL AND PROPRIETARY
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