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.
 

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


This Reagent Deposit Form sets forth the terms governing the transfer of certain research materials (Reagent(s)) from the Depositor's Institution, as indicated below, to the National Institute of Allergy and Infectious Diseases (NIAID) for distribution by the Schistosome Related  Reagent  Repository (SR3), a program managed by the Biomedical Research Institute (BRI).

The terms specified below will be effective on the date that this form is signed by a duly authorized official of the Depositor's Institution.


Depositor's Institution 


Depositor's (Investigator)

1.  Depositor provides to NIAID the following Reagent(s), described in detail on the attached Reagent Information Form (s), for use solely by the NIAID and BRI in connection with operation of the SR3:




2.  To the extent that the Reagent(s) is/are amplifiable, Depositor and Depositor's Institution authorize the SR3 to amplify, aliquot and store the Reagent(s) solely for use by the SR3.

3.  Depositor and Depositor's Institution authorize distribution of the Reagent(s) by the SR3 only to eligible Requesters registered with the SR3.
 
Depositor (Investigator)
Duly Authorized for Depositor's Institution*
 

Signature


Printed Name


Date



Signature


Printed Name and Title


Date
  Mailing Address:
   
  Telephone Nr. Fax Nr.
  email:    
  SR3 Registration Number:  
       
 
* An official capable of legally binding your Institution

The reagent and completed forms should be sent to:
 

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