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.

Waiver of 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
 

This form must be completed by individuals at institutions that cannot sign either the Standard Indemnification Agreement or the State Institution Compliance Agreement.

The Recipient Institution, is unable to comply with the Standard Indemnification Agreement or, if it is a state institution, with the terms of the State Institution Compliance Agreement. As a result, the recipient acknowledges that the NIAID Schistosome Related Reagent Repository will not provide reagents identified by a biohazard symbol.
  *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