ConfidentialPage 1 of 411/28/2018

Request for NIBSC CJD Resource Centre Samples

Reagent(s) Requested:Spiked Plasma Panel

Sample / Quantity
Please SelectNHPM0/0015 Spiked Plasma Panel2 x Plasma 1ml / 01234
Please SelectNHPM0/0015 Spiked Plasma Panel2 x Plasma 1ml / 01234

Justification for request (continue on separate sheet if necessary):

Have you ordered samples from this resource before?

Source of funding (give details):

Reagents, and know-how associated with their use, are provided on the following conditions:

  1. You will not permit the Materials or any part of them to come into the possession or control of any other person except those engaged in research under your supervision who have accepted the same obligations as yourself in respect of the Materials.
  1. You will use the Materials for research purposes only and will not use them or permit them to be used in any way for the production or sale of any products for commercial purposes.
  1. The Materials (or materials derived from them) WILL NOT be used in humans.
  1. Where results and/or discoveries made by you from the use of the Materials may be of commercial value, you agree to ensure timely notification of the donor of the reagent and to withhold publication or oral presentation of these results for a minimum of 30 working days to allow them the opportunity to assess if all steps have been taken to protect Intellectual Property.
  1. All publications or presentations of your work with the Materials will duly acknowledge the original donor of the Materials, the CJD Resource Centre, NIBSC, South Mimms, Pottersbar, EN6 3QG. Copies of such publications will be sent to the Resource Manager at the address given below.
  1. On conclusion of the research programme using the Materials, you will offer any remaining Materials to the Reagent Project and you will continue to abide by the obligations and restrictions set out in this letter.
  1. Any infectious or potentially infectious materials will only be handled in appropriate containment facilities by fully trained and competent staff in accordance with the appropriate national guidelines. (E.g. Transmissible Spongiform Encephalopathy Agents: Safe Working and the Prevention of Infection, Advisory Committee on Dangerous Pathogens: Spongiform Encephalopathy Advisory Committee, available from The Stationery Office, London). NIBSC, accept no liability whatsoever for any damage, injury or death resulting from the use of these materials.
  1. Although all reasonable steps are taken by NIBSC to ensure that any reagents supplied to researchers are those ordered by the researchers, the NIBSC accepts no liability whatsoever for any damage, injury or death resulting from either the supply of any reagents which is not a reagent requested by the researcher or the supply of any mislabelled or mis-described reagent.
  1. The Recipient understands and agrees that the Materials and the Information are provided on an "as is" basis and as such without any warranty or representation of any kind (express or implied) including, without limitation, of satisfactory quality or fitness for a particular purpose or that the use or supply of the Materials or the Information will not infringe any Intellectual Property Rights or other rights of any third party. Specifically, the Provider does not warrant or represent that the Materials are uncontaminated. In addition, the Materials and the Information are provided without any warranty or representation of satisfactory quality or fitness for the manufacture of products used to treat humans. The Provider does not warrant or represent that Materials supplied with any stated phenotype are representative of any particular disease or behavioural model or genotype.

If the foregoing conditions are acceptable to you, please complete and return this form, when arrangements will be made for the despatch of the Materials to you. You may wish to take a photocopy of this form for your records.

We certify that we have read and accept the conditions listed above. We agree to undertake payment for handling and delivery charges, set by the CJD Resource Centre. See web document

(Principal Investigator/Head of Department or Institute)

Address:

Post Code:

Fax:

Email:

Name:

Telephone:

Please supply details of the person in your laboratory who will be responsible for the receipt of the samples:

Email:

(Laboratory Contact in charge of receipt of samples)

Address to which the invoice should be sent:

Address:

Telephone:

Fax:

Name:

Post Code:

Address:

Name:

Reference/ Order Number:

Fax:

Email

Postal code:

Telephone:

VAT Number (European [non-UK] requests only):

Please enter any special notes that should appear on the package

Address:

Brokers Details:

Name:

Reference Number:

Fax:

Email

Postal code:

Telephone:

The samples are positive for TSE infectivity. This material will be shipped as an infectious agent. Do you require an import permit, or to have special documentation attached to the package?

If yes, please attach, as the samples cannot be dispatched until this is received at NIBSC.

I certify that I have read, understood and accept the conditions in this 4 page document.

I understand that these reagents contain infectious materials. These will be handled only in appropriate containment facilities by fully trained and competent staff in accordance with my national safety guidelines. I accept full responsibility for the use and disposal of the material. (For non-UK recipients) I confirm that these materials may be legally imported without delay in their delivery.

Signed:Print Name:

Date:

Please return to Dr J Cooper, CJD Resource Centre, National Institute for Biological Standards and Control, Blanche Lane, South Mimms, Potters Bar, Herts, UKEN6 3QG.

Please note you can initially fax a request to speed up dispatch of samples, however please can you send the original inked document.

Fax: +44 (0) 1707 641 050Tel: +44 (0) 1707 641 511

email:

Document Version 1.03 created 16/06/05