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.

U.S. State Institution Compliance 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
  To be used by individuals at state institutions in the United States only. Individuals at private (for-profit) institutions may not submit this form.

Researchers at public institutions in the United States that cannot sign the Standard Indemnification Agreement must complete the State Institution Compliance Agreement in order to obtain reagents identified by a biohazard symbol. Researchers at public institutions that are unable to accept the terms of either the Standard Indemnification Agreement or the State Institution Compliance Agreement must complete the Waiver of Indemnification Agreement; such individuals will not be able to receive reagents identified by a biohazard symbol.

As a Receiving Party of reagent(s) (the "Substances") from the NIAID Schistosome Related Reagent Repository , the Recipient Institution, agrees to be responsible for 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 to the extent permitted under the laws of this State. The individual executing this agreement on behalf of the Recipient Institution warrants that the individual has full authority to do so.
  *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