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Do you want to link to other websites and leave Amgen.com.au?

You are now leaving Amgen Australia’s website. Amgen Australia takes no responsibility for the information contained on the Amgen international server or site which you will be accessing. The information you are about to access may not comply with the Australian regulatory environment.

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

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Detailed Program Description


What is the title of your event, program or project?
Please provide the full legal name of the requesting institution / organisation
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 healthcare institution / organisation?

What are the start and end dates of the event, program or project? (dd/mm/yyyy format)
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?

Detailed Donation Requirements


What is the total amount (in AUD$) requested from Amgen?
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.

Payee Information


Please provide the full legal name of the requesting institution / organisation.
Please provide the full legal address of the requesting institution / organisation
Address1
Address2
Suburb
State
Postcode
Is the requesting institution / organisation a not-for-profit or tax-exempt organisation?
Yes   No
If yes, enter the organisation's ABN:



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Amgen is collecting personal information in this form in order to assess your request. Amgen is dedicated to handling personal information according to your preferences and our legal obligations.

For this purpose, Amgen may disclose your personal information to Amgen's related entities, as well as to trusted third parties and suppliers who assist Amgen. These related entities and third parties may be located in other countries including the United States of America and in Europe and Asia. Amgen remains accountable for all personal information it discloses and takes appropriate measures to ensure that the confidentiality of your information is safeguarded.

Your personal information will be handled at all times in accordance with Amgen's privacy policy (available at: http://www.amgen.com.au/privacy/privacy_terms.html)

If you have any questions or comments about this Privacy Statement, or wish to access or correct your personal information or make a privacy complaint, please contact our Privacy Officer at:

Amgen Australia Pty Ltd
Level 7, 123 Epping Road
North Ryde, NSW 2113
Attn: Privacy Officer Email: privacyoffice@amgen.com; Tel: +61 2 9870 1333.