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Courtesy of Dr. Frederic Erbisch, University of Michigan, USA, e-mail: eerbisch@juno.com

(Please attach this form to the Material Transfer Agreement (MTA) you wish to have signed)

Principal Investigator:______________________________________________________

Name of contact person: ___________________________________________________

Address: ________________________________________________________________

Telephone Number: _______________________________________________________

Name/Type of Material: ____________________________________________________

In order to appropriately evaluate the attached MTA for approval and signature please answer the following questions.  You may use additional sheets if you require more space for your answers.

a.    What is the intended use of the Material?

b.   Will you be modifying (creating a new substance that contains or incorporates) the Material?  No   Yes, if so, how?   or Unsure

c.    Will any progeny, derivatives or modifications to the Materials be produced? No   Yes, if so, how?   or Unsure

d.    What is the original source of the Material?              

e.   Do you intend to publish your findings?    No        Yes

f.    Is the Material known to be toxic?           No        Yes, if so, describe its toxic qualities.

g.   Have you received the Material already?  No        Yes, if so, when?

h.   Will the Material be used in any research project funded by the government?          No        Yes

i.    Will the Material be used in any research project supported by industrial or foundational sponsors?              No        Yes, if so, name the supporting organization.

j.    Will the Material be used in conjunction with other “borrowed” materials from other parties?  No        Yes, if so, provide more information on the “borrowed” material(s) and the provider(s) of the material(s).

k.   Is the Material sold commercially?           No        Yes, if so, what would the amount of Material you are requesting cost?

l.    Is the Material available from another source?       No        Yes, if so, from whom?

Please add any additional information that you believe to be pertinent.  Once you have completed this questionnaire, please return it to the appropriate organizational office together with the MTA.

Signature ___________________________________  Date ____________________