/ Principal Investigator and Division
Gift Approval Form /

Proposal No. Click here to enter text.

Sponsor Name PrimarySponsor.companyProfile.name»

Principal Investigator «_attribute0.fullName()»

Division Click here to enter text.

Project Title «description»

Type of Gift ☐Monetary Gift ☐Equipment Gift

Amount of Gift Click here to enter text.

Yes☐ / No ☐ / Human and/or animal subjects are involved in the proposed work. Work will not begin until appropriate LBNL/UC approvals have been obtained.
Yes☐ / No ☐ / The work shall be on a non-interference basis with DOE related work.
Yes☐ / No ☐ / The work enhances the capabilities of the Laboratory to continue to perform its mission or create new capabilities consistent with overall needs of DOE.
Yes☐ / No ☐ / The Laboratory will not knowingly use its access to Laboratory facilities under this gift to compete with the private sector.
Yes☐ / No ☐ / The Laboratory will not use any funds pursuant to this gift to augment any federally funded research.
Yes☐ / No ☐ / The Laboratory will not knowingly pursue any projects with this gift that include facilities or equipment that would create more than a nominal future burden on DOE resources to maintain and/or operate.
Yes☐ / No ☐ / Is this a non-Federal Sponsor exempt from State of California Conflict of Interest requirements?
If No, complete the State of California Form 700U in accordance with RPM 10.01 - Conflict of Interest and upload it into the proposal in eSRA.

(Page 1 of 2 Pages)

Proposal No. Click here to enter text. (2nd of 2 pages)

Principal Investigator Approvals
The Principal Investigator certifies the following prior to submission of the proposal to the Industry Partnerships Office:
·  The information contained herein and in the proposal is true, accurate, and complete.
·  I ensure the Gift is not a Work for Others project.
·  I am not debarred, suspended, proposed for debarment or voluntarily excluded from current transaction by a federal agency or departments.
Date: Principal Investigator Approval:
Date: Other Principal Investigator (if any) Approval:
Division Approvals
The Division Director is responsible for evaluating and approving this proposal prior to the submission to the Sponsored Projects Office. The basic consideration and commitment given a proposal in the review include:
l Ensuring the Gift is not a Work for Others Project
l Determining project appropriateness to LBNL and DOE
l Considering the possible deflection of key personnel from LBNL's primary research programs
l Determining requirements for and availability of space, support, and equipment
l Ensuring compliance with LBNL, DOE and University policy
l Evaluating the proposal in light of any Conflict of Interest declaration
l Assuring the safety of personnel and protection of the environment
Date: Primary Division Approval:
Date: Other Participating Division(s) (if any) Approval: