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MATERIAL TRANSFER AGREEMENT REQUEST FORM
(Applicable only when Non-CUNY party is supplying the material)
1. / Details of the material:Exact Name:
Nature of Material:
(Chemical compound, micro-organism etc)
Does it contain cre-DNA or lox-DNA:
2. / Please outline your planned use (or research plan) of the material. Will you create derivatives or make modifications to the material? If so, please list potential derivatives or modifications?
3. / Is this material available commercially? If so, what is the commercial price?
4. / Has the material been described in a publication or presented at a conference? Please provide the reference.
5. / Will you receive any information about the material which might be considered confidential or proprietary?
6. / Will the material be used in conjunction with other materials or equipment which was received from other providers?
7. / Do you have any collaborators (at CUNY or other institutions or a company) on the project where the material will be used?
8. / Will the anticipated research or results using the requested material have novel clinical or commercial applicability?
9. / Do you have any other active contract with this company?
10. / Please indicate all sources of support (NIH, foundations grants, fellowships, industrial support etc) for the project. Will you use industrial support for any portion of the PI’s salary or salary of individuals working on the project related to the material, or the purchase of any lab supplies required for the project?
11. / Does your lab receive industrial support for any portion of the PI’s salary or salary of individuals working on the project, or the purchase of any lab supplies required for the project?
12. / Name of requesting person:
Address:
Telephone:
E-mail:
Signature:
Date:
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