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

  Name
  Title
  Institution
  Laboratory/Department
   
  Full Shipping Address  
   
   
   
  Mailing Address (if different from Shipping Address):
   
   
   
  Telephone
  Fax
  email
  NOTE: All Reagents will be shipped to the above mailing address.
Reagents cannot be shipped to a post office box.
  Safety Officer
    Printed Name/Signature
  Type of institution is (select one):
  University/Education
Biotechnology/Life science
Pharmaceutical/Drug Discovery
Hospital/Clinic
International Government
Government (CDC, NIH, USDA, FDA etc.)
Research/Foundation
Other (explain )    
  a non-profit organization
a commercial organization
 
 

TERMS AND CONDITIONS FOR USE OF REAGENTS
OBTAINED THROUGH THE SR3

For participation in the SR3 program, including deposition and use of research materials or Reagents, the Registrant and the Registrant's Institution agree to the following terms:

1. Certification of Compliance with Safety Standards
Registrant and Registrant's Institution are aware that all Reagents distributed by the SR3 may be potentially bio-hazardous even when they are not specifically designated by a biohazard symbol. Registrant and Registrant's Institution understand that the requested Reagent(s) may pose health risks to persons handling or in the vicinity of the Reagents, the environment and the community. Registrant and Registrant's Institution certify that Registrant and Registrant's Institution are cognizant of and will employ the appropriate bio-safety standards including special practices, Institution and Government health and safety regulations and the guidelines detailed in Bio-safety in Microbiological and Biomedical Laboratories, 3rd Edition, DHHS Publication No. (CDC) 93-8395, May 1993, or the most recent revision of these guidelines. Registrant and Registrant's Institution will directly supervise all users of the Reagent(s), and Registrant and Registrant's Institution will assume responsibility for assuring that those users of the Reagent(s) are cognizant of and comply with applicable safety standards and good laboratory practices.

2. Certification of Use
Except as provided in Term 3 below, Registrant and Registrant's Institution certify that all Reagents provided to Registrant by the SR3, or unmodified derivatives of said Reagents, will be used for research purposes only, in Registrant's laboratory only, at Registrant's Institution only, and only for the purpose described on the Reagent Request Form. Registrant and Registrant's Institution understand that unmodified derivatives include substances created through Registrant's use of a Reagent that constitute an unmodified functional subunit or product expressed by the Reagent. Registrant and Registrant's Institution agree not to distribute the Reagent(s) or unmodified derivatives thereof to any persons except those engaged in research at the Registrant's Institution.

3. Commercial Uses
Registrant and Registrant's Institution will not use any Reagent received from the SR3 for any commercial purpose without first obtaining a suitable commercialization agreement with the owner ("Depositor's Institution") of the Reagent unless the Reagent Information Form for the Reagent indicates that the Reagent can be used for any purpose including commercial purposes. Registrant and Registrant's Institution agree that Reagent(s) requested for research purposes will not be used for commercial purposes unless Registrant and Registrant's Institution obtains a suitable commercialization agreement with the Depositor's Institution BEFORE using the Reagent(s) for any commercial purposes.

4. Human Use
Registrant and Registrant's Institution agree to comply with Protection of Human Subjects, Title 45, Code of Federal Regulations, Part 46. Registrant and Registrant's Institution will not use any Reagent(s) obtained from the SR3 nor any derivative(s) of said Reagent(s) in humans or for any clinical diagnosis without receiving prior written approval of the Depositor's Institution and the Director, Division of Microbiology and Infectious Diseases, NIAID, NIH.  The intent of these conditions is to protect both the rights and the welfare of human subjects and to protect Depositors of Reagents as well as the SR3.

5. Animal Use
Registrant and Registrant's Institution agree that any Reagent(s) provided by the SR3, as well as 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 most recent 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).

6. Assumption of Shipping Costs
Registrant and Registrant's Institution agree to assume responsibility for all shipping costs incurred by the SR3 in the handling and delivery to Registrant of any Reagent(s) requested by Registrant.

7. Acknowledgement of Source
Registrant and Registrant's Institution agree to acknowledge in all publications and presentations that describe Registrant's use of Reagents supplied by the SR3 both the Depositor of the Reagent(s), as indicated on the Reagent Data Sheet, and the SR3.  The suggested format for such acknowledgement is:  "The following reagent was obtained through the Schistosome Related Reagent Repository (SR3) , Division of Microbiology and Infectious Diseases, NIAID, NIH: (Reagent name) from (Depositor)."

8. Reporting Requirement
Registrant and Registrant's Institution agree to provide the SR3 with a description of Registrant's intended use of the requested Reagent(s) with each request. Registrant and Registrant's Institution agree to provide to the SR3 once per calendar year a listing of published (electronically or in hard copy) research papers, reviews and abstracts reporting Registrant's use of Reagent(s) obtained from the SR3.  Registrant and Registrant's Institution understand that their obligation to provide Annual Reports to the SR3 will end when Registrant and Registrant's Institution have used up or destroyed the Reagent(s) and any derivatives of the Reagent(s) and have provided written notification thereof to the SR3.

9. Warranties and Limitation on Liability
Registrant and Registrant's Institution acknowledge that, with respect to any Reagent(s) provided by the SR3, no warranties of any kind are extended by the Depositor, the Depositor's Institution or the SR3, either expressed or implied, including but not limited to warranties of ownership, merchantability, or fitness for a particular purpose.  Moreover, Depositor, the Depositor's Institution and the SR3 make no representation that the use of Reagent(s) will not infringe any patent or proprietary rights of third parties.  In no event will the NIAID, its contractor for the SR3 or any other person or entity associated with the SR3 be liable for any incidental or consequential damages of any kind, including but not limited to economic damages or injury to person or property or lost profits, whether or not the same shall know or have reason to know of the possibility of the foregoing.  In no event will the NIAID, its contractor for the SR3 or any other person or entity associated with the SR3 be liable to Depositors of Reagents to the SR3 for misuse of the Reagents by Requestors of the same including but not limited to the unauthorized commercial use of any Reagent(s).

10. Duration of Agreement
Registrant and Registrant's Institution understand that the terms of registration with the SR3 are effective for five (5) years from the date registration is confirmed by the SR3.  Further, Registrant and Registrant's Institution understand that NIAID or Registrant's Institution may terminate this registration by written notice to the other Party at least thirty(30) days in advance of the desired date of termination.  On termination or expiration of this Agreement Registrant and Registrant's Institution will destroy or return to the SR3 any remaining Reagent(s) obtained through the SR3 and provide written notification thereof to the SR3 no later than the date of termination.

     
  Registrant (Investigator) Duly Authorized for Registrant's Institution*
     
 
  Signature Signature
     
 
  Printed Name Printed Name and Title
     
 
  Date Date
     
    Mailing Address
   
   
   
  SR3 Registration Number  
     
  *An official capable of legally binding your Institution

Checklist for Application:
1. Is the Registration form completed and including proper signatures for Registrant; Safety Officer and Authorized Institution head?
2. Did you complete the required Indemnification Form?
     
 

Completed Registration Forms should be mailed to:

 

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

 

REGISTRATION FORMS SENT BY FAX OR EMAIL WILL NOT BE ACCEPTED.