Lilly Grant or Charitable Donation Application - Part II

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1 Important Information - Please Read Lilly strives to provide funding to organizations and institutions that support and enable the advancement of patient care and healthcare delivery. Each request will be reviewed on its merit. Lilly and requesting parties have the right to publicly disclose information concerning any or all approved grants, including but not limited to, the amount of funds disbursed, to whom the funds have been provided, a description of the grant activity, and the date funds were given. Please carefully read the instructions below before completing your application: Lilly will use its best efforts to provide a decision to you as quickly as possible. However, please be advised of the following: (1) It may require up to 4 weeks to diligently review and process your application once all of the necessary documentation is submitted to Lilly (2) If Lilly does not receive all necessary documentation at least 4 weeks before the date of your program, Lilly will not consider your grant request. DOCUMENTATION TO SUBMIT: Application Signed and Dated Please Note: Lilly will not review your application without all necessary supporting documentation, see page one for requirements. Application Process; Part II Having now been notified by Lilly of your application's conditional approval through Part I of the application process, it is now necessary to complete this form - 'Lilly Grant or Charitable Donation Application ' to comply with our Integrity in Business Guidelines. Only upon internal approval of this form shall the overall Grant or Donation application be approved as successful. Lilly shall notify you throughout the process as to your application progress. Integrity in Business; Lilly's Anti-Corruption Compliance Assessment Lilly is committed to ensuring that any funding it may provide does not violate applicable law. UK law, United States law and international law prohibit Lilly from providing funding that will be used to benefit any government or public official, directly or indirectly, for the purpose of obtaining or retaining business for Lilly or for any improper purpose. The following questions are intended to provide Lilly with information it needs to ensure compliance with these applicable anti-corruption and anti-bribery laws. It is important that you complete the following questions accurately and completely. Definitions for use in the Anti-Corruption Compliance Assessment Government or Public Entity May refer to any of the following: 1. A government or any department, agency or institution thereof; 2. A government owned or controlled agency, institution, or other entity, including a government-owned hospital or university; or 3. A public international organisation (such as the United Nations, the International Monetary Fund the International Red Cross and the World Health Organisation) or any department, agency or institution thereof; 4. A political party or an organisation owned or controlled by a political party or a candidate for public or political party office. Government or Public Official 1. Refers to any officer or employee or other person acting in an official capacity (whether or not paid) on behalf of a Government or Public Entity. T AA Page 1 of 6

2 Section 1: Individuals with Government Relationships and/or Influence on Lilly Business 1. Does your organization or any individual on its Board of Directors, any senior management employee or any key employee who interact with Lilly fit the following descriptions? IS THE ORGANISATION: Yes No A government or any department, agency or institution thereof A government- owned or controlled agency, institution or other entity, including a governmentowned hospital or university A public international organization (such as the United Nations, the International Monetary Fund, the International Red Cross, and the World Health Organisation) or any department or agency thereof A political party or an organization owned or controlled by a political party Other government relationship. Please explain ARE ANY INIDIVIDUALS: Yes No A current elected or appointed official, employee, agent or representative of any government agency or institution or government-owned or government-controlled company A current political party official or employee or an individual working on behalf of a political party or political campaign A current candidate for or elected individual holding a political office A current officer, agent, or employee of a publicly funded or public international organization (i.e. UN, IMF, Red Cross, WHO, etc.) Other government relationship. Please explain: 2. Does your organisation or any individual on its Board of Directors, any senior management employee or any key employee who interacts with Lilly have authority within your organization or elsewhere to make or influence decisions or recommendations regarding ANY of the following? Yes No Official pricing of Lilly products Formulary status of Lilly products Reimbursement of Lilly products Institutional purchase of Lilly products, for companies, institutions, organizations, etc., Approval of registrations, permits or other authorizations related to Lilly products Any other registrations, permits or authorizations related to other Lilly business interests Other influence. Please explain: Please note: Influence does not include prescribing Lilly products to individual patients in the course of a healthcare professional s normal medical practice. T AA Page 2 of 6

3 3. If you indicated yes to any items in Question 1 or 2, please provide the following additional information for EACH person: In addition, please ensure that a Privacy Notice (Section 3) is signed by each individual named below: Person's Full Name Position at or Relationship with your Organisation Type of Services this Person will Provide to Lilly (If any) Organisation (s) Involved Nature of Person's Relationship with the Organisation (eg Job title) Nature of Influence Related to Lily Products / Business (If any) 4. Are there any employees of your organisation who can influence Lilly s business that have not been disclosed in the answers to the previous questions? Yes If yes, provide the following information requested below. In addition, please ensure that a Privacy Notice (Section 3) is signed by each individual named below: Full Legal Name Describe Nature of Influence No 5. Explain any circumstances in which the organisation or any employee of the organization, member of the Board of Directors, or other individual identified in response to questions 1-4 will interact with government agencies or officials in connection with any grant or donation provided by Lilly: 6. Beyond the stated purpose of the request, if approved, will any portion of the grant or donation be re-directed to any other individual or organization? Yes No If yes, provide the following information requested below. Individuals' or Organisations' Full Name Amount of Grant or Donation to be re-directed Purpose for which the re-directed part of the Grant or Donation will be used T AA Page 3 of 6

4 Section 2: Privacy Notice and Certification Lilly Grant or Charitable Donation Application PRIVACY NOTICE This questionnaire requires that you provide Lilly with certain personal information about yourself and, potentially, other third parties. This includes information such as your name, contact details, and associations you might have with local government or public officials. Please note that your questionnaire will be retained by Lilly UK and a copy may be furnished to Lilly s Anti-Corruption Compliance Programme located at Indianapolis, Indiana U.S or in other countries whose privacy laws may not be equivalent to those in the UK. Lilly will enter into appropriate contractual arrangements with such third parties requiring them to maintain this information securely and not use it for any purposes, other than those specified in this notice and on this form. Access to this information will be available to Lilly employees in the country in which you reside and to individuals within Lilly s global anti-corruption, compliance and legal divisions, some of whom may be in the United States and other countries outside of the European Union, but only to those employees whose work reasonably requires Lilly will review and assess your responses in order to ensure its compliance with domestic and U.S. laws, including domestic and foreign anti-corruption laws and other laws and regulations that are applicable to the company. Lilly may conduct media searches and check names provided in this document. In the event that potential compliance concerns are identified, information that you provide may be shared with Lilly s external legal advisors and/or domestic and foreign regulatory authorities, such as the US Securities and Exchange Commission and domestic legal authorities. In accordance with Lilly s normal auditing practices and procedures, your questionnaire may later be selected and reviewed by Lilly s internal corporate audit department or its external auditors. Should you wish to access or, if incorrect, amend or delete the personal information Lilly holds pertaining to you, please contact Legal Department by calling Where you provide us with personal information relating to third parties, including business partners, you only may do so after having notified these individuals about the purposes for and manner by which their information will be collected and processed by Lilly, as described above and after providing them with the contact information set forth above, should they have questions or wish to exercise their data protection rights. By signing and submitting this form, you acknowledge and agree to furnish such notice and Lilly will not be held responsible for any loss or harm that may result as a result of your failure to do so. By signing below you are also agreeing to allow the processing of your information as described in this notice and on the questionnaire. External Party Certification I hereby certify: That I am a duly authorized representative of the organization named below; That the information I have provided is true and complete to the best of my knowledge; That I understand that Lilly will rely on this information in deciding whether to provide a grant or donation to the organization; That I consent to Lilly storing and transferring this information in accordance with applicable law; That in connection with any grant or donation that may be provided by Lilly, no officer, director, owner, employee, agent or representative of the organization has given or will give or attempt to give anything of value, directly or indirectly, to a Government or Public Official, or any political party or candidate for public or political office, or any other individual or entity for transfer to any of the foregoing for the purpose of obtaining or retaining any business or gaining any improper advantage; That Lilly may publicly disclose information regarding any grant or donation that Lilly may pay to the requesting organization, including the date on which the grant or donation is provided, the amount of the grant or donation, the organization receiving the grant or donation, and the purpose for which the grant or donation is provided; That I understand that the information I provided on this form, as well as all information about me and others referenced on this form and related to the purpose of this form, may be used by Lilly in accordance with the Privacy Notice. I also certify that I have appropriate permission to provide the information I have provided about family members and all other individuals about whom I have provided information and that I will provide these individuals with the Privacy Notice contained in this document Signature: Date of Signature: Full Name: Position Title: Organisation: Next Steps To complete this form, before submitting back to Lilly, please: Print out this completed form and sign & date above Please return all completed documents to the Grants and Donation Committee Secretary by: Post: Grants & Donations Secretary, c/o Eli Lilly & Co, Priestley Road, Basingstoke, Hampshire, RG24 9NL ukgrants@lilly.com T AA Page 4 of 6

5 Fax: T AA Page 5 of 6

6 Section 3: Privacy Notice & External Party Certification (To be completed by any individuals named in this document by the applicant) (Add additional pages if more than one individual is named in this document) PRIVACY NOTICE Information about you has been included in the attached questionnaire, which was completed by the individual who signed the bottom of the questionnaire. This includes information such as your name, contact details, and associations you might have with local government or public officials. Please note that your questionnaire will be retained by Lilly UK, and a copy may be furnished to Lilly s Anti-Corruption Compliance Programme located at Indianapolis, Indiana U.S. Lilly will review and assess the information in the questionnaire in order to ensure its compliance with domestic and U.S. laws, including domestic and foreign anti-corruption laws and other laws and regulations that are applicable to the company. Lilly may conduct media searches and check information about you as provided in this document. In the event that potential compliance concerns are identified, information about you may be shared with Lilly s external legal advisors and/or domestic and foreign regulatory authorities, such as the US Securities and Exchange Commission and domestic legal authorities. In accordance with Lilly s normal auditing practices and procedures this questionnaire may later be selected and reviewed by Lilly s internal corporate audit department or its external auditors. Should you wish to access or, if incorrect, amend or delete the personal information Lilly holds pertaining to you, please contact Legal Department by calling By signing below you are also agreeing to allow the processing of your information as described in this notice and on the questionnaire. External Party Certification I hereby certify: That I am the individual named below and am duly authorized to make representations regarding the information contained in this form; That the information I have provided is true and complete to the best of my knowledge; That I understand that Lilly will rely on this information in deciding whether to enter into any formal business agreement with the individual named on page 4 of this form; That I consent to Lilly storing and transferring this information in accordance with applicable laws; I have not given and will not give or attempt to give anything of value to a Government or Public Official, political party or candidate for political office, or any other individual or entity, directly or indirectly for the purpose of obtaining or retaining any business or gaining any improper advantage; and That I understand that the information I provided on this form, as well as all information about me and others referenced on this form and related to the purpose of this form, may be used by Lilly in accordance with the Privacy Notice. Signature: Date of Signature: Full Name: Position Title: Organisation: T AA Page 6 of 6