PLEASE NOTE: The form in this page cannot be submitted online since original signatures are required prior to submission. However, this form can be completed online and printed prior to obtaining the signatures. The forms must be mailed to the address mentioned in the contact information page. Alternatively, you may download this form in "word" or "pdf" format.

Standard Indemnification Agreement
Send Completed Form to:
SR3/Biomedical Research Institute
12111 Parklawn Dr., Rockville , MD 20852 , USA
Fax:  301-770-4756

  Current Registration is effective for 5 years from date of approval
  Researchers at private universities, foundations, and companies, or at state institutions that can accept the wording of the Standard Indemnification Agreement must complete this form in order to obtain reagents identified by a biohazard symbol. An alternative State Institution Compliance Agreement for researchers at U.S. public institutions that cannot sign this Standard Indemnification Agreement is provided. Researchers at institutions that are unable to accept the terms of the Indemnification or Compliance Agreement must complete the Waiver of Indemnification Agreement; such individuals will not be able to receive reagents identified by a biohazard symbol.  U.S. Government employees are not required to submit an indemnification agreement.

As a Receiving Party of reagent(s) (the "Substances") from the NIAID Schistosome Related Reagent Repository , the Recipient Institution, agrees to indemnify and hold harmless the United States, the Biomedical Research Institute, their suppliers and contributors of reagents, from any claims, costs, damages, or expenses resulting from any injury (including death), damage, or loss that may arise from the possession and use of the Substances or any derivative thereof by the Receiving Party. The individual executing this agreement on behalf of the Recipient Institution warrants that the individual has full authority to do so, and to thereby bind the Recipient Institution.
  *Officer of Institution or Company (Signature) Requestor (Signature)
     
 
  Printed Name Printed Name
     
 
  Title Title
     
 
  Institution Institution
     
 
  Date Date
     
  *The officer cosigning above must be capable of legally binding the institution.
   
  Completed Registration Forms should be mailed to:
 

SR3
Biomedical Research Institute
12111 Parklawn Drive
Rockville, MD 20852
USA