DUE DILIGENCE QUESTIONNAIRE
General Information
The purpose of this form is to provide a mechanism for a potential Grant, Donation or Charitable
Contribution Recipient (the “Recipient”) that may be supported by Genzyme or any of its affiliates to:

provide relevant information to assist Genzyme in its obligations to conduct the Other Party
due diligence process; and
Questionnaire
For the purpose of the Questionnaire, the term “Government Official” shall refer to:

any officer or employee (including any person nominated or appointed to be an officer or
employee) of a government or any department, agency, or instrumentality of a government
(including a government-controlled enterprise);

any person acting in an official capacity on behalf of a government or any department,
agency, or instrumentality of a government;

any officer or employee of a company or business owned in whole or part by a government;

any officer or employee of a public international organization, such as the World Bank or the
United Nations;

any officer or employee of a political party or any person acting in an official capacity on
behalf of a political party; and/or

any candidate for political party.
Additional Resources
For any additional information, please refer to the Genzyme Anti-Bribery Policy and Code of Ethics at
the following website: http://csrreporting.sanofi.com/web/publications_en
QUESTIONNAIRE
All questions must be completed. Please mark questions that are “not applicable” with N/A. If there
is insufficient room on the form, please answer on a separate sheet referencing the question that
appears on the form and attach any additional sheets to this form.
1. Project overview
1.1
Summary of the Recipient’s Project:
1.2
Objectives:
1.3
Total cost of the project:
1.4
Detailed project budget:
1.5
Support requested from Genzyme:
1.6
Other funding sources:
1.7
Other partners or other associations or
organisations in Recipient countries
involved (or will they be involved) in the
project? In particular, explain whether and
how the Regulatory Authorities in the
recipient country are involved. Provide
details of the history of relations between
the Recipient and local partners):
1.8
Projected Results and outcome expected
by the Recipient:
2. Information on the Recipient and its activities
2.1
Full legal name:
2.2
Street address:
2.3
City:
2.4
State/province:
2.5
Country:
2.6
Postal code:
2.7
Telephone number:
2.8
Website (if any):
2.9
E-mail:
2.10
Is the Recipient organisation registered in
the country?
2.11
Main activities of the Recipient:
2.12
In which countries does the Recipient carry
out its activities?
No
Yes. If yes, provide registration number and
validity period below:
2.13
Is the Recipient organisation:
 A government or a
department, agency, or
institution of a government?
 Government-owned or
controlled?
 A public international
organization?
No
Yes. If yes, provide details below:
2.14
Are any of the Recipient key
personnel Government
Officials or directly related to a
Government Official.
No
Yes. If yes, for each individual, list below:
Position/status of the
concerned person in
the Recipient
organisation
The concerned
Government entity or
organisation
Nature of concerned
person’s
responsibilities at
government entity or
organisation
2.15
Has the Recipient or any of its
personnel ever been accused
of, or been interviewed,
subpoenaed, deposed, etc. in
connection with litigation or an
investigation involving
violations of anti-corruption
laws?
No
Yes. If yes, provide details below:
3. Contact person for Genzyme
3.1
Full Name:
3.2
Role in Recipient's
organisation:
3.3
Phone:
3.4
Email:
4. History of partnership with Genzyme group and its affiliates
4.1
Please advise if Genzyme (or any Genzyme
affiliate) and your organisation have already
been partners over the past three (3) years
(provide year, projects, length, department(s)
concerned etc.):
5. List of attached documents
CERTIFICATION
I hereby certify:


That I am a duly authorised representative of the Recipient named below.
That the information I have provided is true and complete to the best of my knowledge.
Signature ............................................................
Date:
Representative Name:
Recipient’s Name:
Title:
Address: