Salesforce CLM Product Donation

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Product Donation Request Form

Requesting Organization Name *

Requesting Organization Address Line 1 *

Requesting Organization Address Line 2

Requesting Organization City *

Requesting Organization State *

Requesting Organization Zip *

Requesting Organization Country *

Requesting Organization Tax ID Number *

Requesting Organization Tax Status *

Requesting Organization Type *

Requesting Organization Contact Name *

Requesting Organization Contact Job Title *

Requesting Organization Contact Email *

Requesting Organization Contact Phone *

Event or Mission Name *

Event or Mission Start Date *

Event or Mission State *

Event or Mission Country *

Event or Mission Description *

Estimated number of patients treated *

Identify the requested product name (or SKU), description and quantity of the product requested *

Requested delivery date of product(s) *

Describe how the donated product will be used *

Full name of Clinician under whose direction donated product will be used *

License number if Clinician *

Credentials of Clinician *

Email Address of Clinician *

Phone number of Clinician *

Country of residence of Clinician *

Name of medical facility where product will be used

Address of medical facility where product will be used

Product shipping information (may not be to a personal address) if products are requested and if different than Organization or Principal investigator information provided above:

Ship To Name

Ship To Address

Ship To Contact Name

Ship To Contact Email

Ship To Contact Phone

Ship To Contact’s relationship to Organization

Will you agree to return any unused product to B.Braun? *

Will your organization be fully responsible for any shipment of donated product across country borders and be named as the exporter of record for any such shipments?

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Product Donation Request Form

Product shipping information (may not be to a personal address) if products are requested and if different than Organization or Principal investigator information provided above:

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