To submit a request for a Material Transfer Agreement for outgoing material (MTA-out), please complete all requested fields in the form. If you have questions, please email:

Please Answer All Questions

  1. HSS Principal Investigator Name:
  1. Recipient Organization Information:

Company/Institution Information

Name:

Address:

City:State: Zip Code:

Country (if applicable):

Postal Code (if applicable):

Recipient Principal Investigator Name:

Shipping Address (if different than above):

Recipient Authorized Person

Name:

Title:

Email:

Phone:

  1. Name of Material(s):
  1. Describe Material Type (Check all that apply)

☐ Animal Model / ☐ Cell Line / ☐ Antibody (monoclonal) / ☐ Antibody (polyclonal)
☐ Protein / ☐ Virus / ☐ Plasmid / ☐ Other nucleic acid
☐ Compound / ☐ Device (non-medical) / ☐ Device (medical) / ☐ Data
☐ Software (encrypted) / ☐ Software (non-encrypted) / ☐ Human Samples / ☐ Human Data
☐ Other (please describe)
  1. Briefly describe the scope of research and the Recipient’s intended use of your Material:

If you would like to place a limit on how long your Material may be used, please enter it here:

  1. Was the Material solely created in your laboratory at HSS?

☐ Yes☐ NoIf no, where was the Material created and by whom:

  1. Does your Material incorporate, or was your Material created using materials from another laboratory at HSS, another university, a company, etc.? ☐ Yes ☐ No

If yes, please identify the name of the material, the source, and indicate whether you have an MTA (you do not need to include off-the-shelf materials purchased without an MTA):

  1. Indicate funding source(s) in which your Material was created (check all that apply)

☐ Industry / ☐ Federal / ☐ Foundation / ☐ HSS
☐ Other (please describe)
  1. Does this Material or research related to a HSS invention or HSS intellectual property?
    ☐ Yes☐ No

If yes, please provide invention information:

  1. Are you sending this Material as a straightforward transfer of materials and not to collaborate with the Recipient PI in any other way?

If no, did you develop the protocol?☐ Yes☐ No

If no, do you expect joint publication (co-authorship) of research results?☐ Yes☐ No

Please describe how you and the Recipient PI will each contribute to the collaboration, your expectations regarding potential revenue sharing from inventions that may result from the collaboration, etc.:

  1. Do you wish to charge a fee for reimbursement of preparation/handling of the materials(s)?

If yes, enter suggested amount:

  1. Do you have any agreement form(s), document(s) or correspondence from the Recipient Party we need to obtain from you?

☐Yes

☐No

  1. Please feel free to provide any additional comments