Donation Request Form

 

Here are a few things to consider when submitting your Donation request:

A Donation is funding or goods or services provided to a charitable or a non-profit organization, where the support is intended to advance the efforts of the organization and have a positive impact on the community, without the expectation of anything of value in exchange.

Please note that we cannot award charitable donations directly to healthcare practitioners or healthcare organizations.  A donation can only be awarded to a registered charitable organization in Canada.

At LEO Pharma Inc. ("LEO"), we strive to support and inspire others in our efforts to make a positive difference in the lives of Canadian patients.

As a foundation-owned and patient-centric company with limited funds, we are able to fund only certain charities such that we can maximize our impact. You are welcome to apply for a charity donation. Please be advised however that LEO directs almost all of our charitable donations towards one key charity, Health Partners International of Canada, and very few select patient organizations.


All fields marked with must be completed in order to process your request. We aim to notify applicants within 90 days of receipt.

Applicant Organization Details

Who is your LEO Pharma Contact Person? * 
Requestor's Name * 
Requestor's Title * 
Institution/Organization/Clinic name *: 
Funds made payable to (Organization name) *: 
All funds are paid by EFT. If your G/D/S request is approved, we will contact you for EFT information.
If you prefer to receive funding through Electronic Fund Transfer (EFT), please check here *:
 
GST / HST Exempt? * 
GST / HST # * 
QST # 
Prefix 
Contact Name 
Contact Title 
Address 1 * 
Address 2 
City * 
Province * 
Postal Code * 
Country * 
E-mail address * 
Website 
Phone Number * 
Ext # 
Is your Organization a Registered Canadian Charity? * 
If yes, please provide Registered Charity Number: 

Funding Details

Total amount requested (CAD) *: 
What purpose or project will the donation be used to support? * 
Agreement contract made out to (individual’s name) *: 
Please attach any supportive letters or documentation here: