Cell Line Release Authorisation for Research Use in Commercial Organisations
Release of this cell line for research use by commercial organisations requires the Depositor’s permission. Therefore commercial organisations wishing to purchase this cell line for research use must complete section one of this form and send to the Culture Collections before the order can be processed. Please note that the Culture Collections Standard Terms and Conditions will apply. See http://www.phe-culturecollections.org.uk/orderinginfo/terms.aspx.
See appendix 1 for name and catalogue numbers of the cell lines which require this form.
Section 1 - CustomerPO/Order Number: Click here to enter text.
(Please enter your customer purchase order number, website reference or Culture Collections order number)
Cell Line Name: Click here to enter text. / Catalogue Number: Click here to enter text.
Name of requesting scientist: Click here to enter text. / Position: Click here to enter text.
Organisation: Click here to enter text.
Address: Click here to enter text.
Phone: Click here to enter text. / Email: Click here to enter text.
Intended Use of cell line: Click here to enter text.
Signed:
(requesting scientist) / Date:
Culture Collections contact details for the return of this form
Email: /
Fax: / +44 (0) 1980 611315
Post: / Culture Collections, Public Health England, Porton Down, Salisbury, Wiltshire, SP4 0JG, UK
Internal use only - Depositor / Technology Transfer Office
Hiroaki Horikawa
Product Management & Business Development
Cell Science Division
DS Pharma Biomedical Co., Ltd.
6-5, Tsuruno 2-chome, Settsu,
Osaka, 566-0035, Japan
Main Tel: / Direct Tel:
Fax: / +81-72-634-7222 / Email: /
Section 2 – Depositor / Technology Transfer Office - Authorisation for sale
I agree to release this cell line to the customer named in section one for the intended use / r Yes r No
Signed: / Date:
Print name:
Once signed please return this form to the Culture Collections using the contact details at the bottom of section one
Section 3 – Culture Collections - Authorisation for sale
Supervisor Signature: / Date:
Print name:
Culture Collections – a Public Health England biological resource
Supporting the scientific community with quality, integrity and expertise www.phe-culturecollections.org.uk
Page 2 of 2 Effective Date: 08.01.2016 Authorised by: Bryan Bolton Document number: ECCW229.01-16 (M053)
Appendix 1
List of cell lines that require this form to authorise release for research use in commercial organisations
Cell Line Name / Catalogue Number4-11 / 11033103
HeB5 / 11033104
HeLa9903 / 11033105
HeLa/MMTV-luc / 11033106
Culture Collections – a Public Health England biological resource
Supporting the scientific community with quality, integrity and expertise www.phe-culturecollections.org.uk
Page 2 of 2 Effective Date: 08.01.2016 Authorised by: Bryan Bolton Document number: ECCW229.01-16 (M053)