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 Request Form
Send Completed Form to:
SR3/Biomedical Research Institute
12111 Parklawn Dr., Rockville , MD 20852 , USA
Fax:  301-770-4756
  SR3 Registration Number:
  Name of Registered Requestor:
  Telephone Nr.
  Fax Nr.
  Email:
  Shipping Address:
      
      
      
   
  IMPORTANT: Attach required Permits (When a permit is required and not included with this order, you will be notified and given 2 months to send it. After that time, the order will be cancelled)
  Shipping and Handling - Although reagents are sent free of charge, you are liable to pay for these charges
  Payment Type (check one):
  American Express MasterCard Visa Card
  Credit Card Number
  Name on Credit Card
  Expiration Date (MM/YY)
  Signature
 
OR
  
  Fedex /UPS/ Other billing account No
     
  Animal Welfare Assurance No
(if a reagent is to be used in animals):
   
 

NOTE: *If there is a commercial development or usage on reagent, place check mark in box and complete "Acknowledgement of Commercial Rights Form".

  *Commercial Development    
  Catalogue   Reagent
 
 


I request the reagents listed on the SR3 list.  I agree to adhere to all conditions and agreements in my Registration Form.  I agree that reagents provided by the SR3 and any derivatives of said reagents will be used in animals only as described in: Public Health Service Policy on Humane Care and Use of Laboratory Animals, March, 1996, or the latest version thereof (copies may be obtained from the NIH Division of Animal Welfare, TEL: (301) 496-7163, or the U.S. Government Printing Office, Publication No. 249-260).

I agree to comply with Protection of Human Subjects, Title 45, Code of Federal Regulations, Part 46.  I agree that none of the reagents provided by the SR3, nor any derivatives of said reagents, will be used in humans or for any clinical diagnosis without receiving prior written approval of the reagent donor and the Director, Division of Microbiology and Infectious Diseases, NIH.

I agree to adhere to the depositor-assigned requirements for commercialization of the reagents I receive from the SR3.

I agree to the responsible for an annual reporting agreement until I no longer have the reagent(s) or derivatives of the reagent(s) in my possession.

   
  PERSONNEL ENGAGED ON PROJECT
  Name
  Position Title
   
  ONLY THE REGISTERED REQUESTOR MAY SIGN THIS FORM.

Registered Requestor (Signature) and date

  Completed forms should be sent to:
 

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