Initial Application Form - LifeGene

1. Applicant information
Complete name Postal address

E-mail address

Phone number (including country and area codes)

Institution/Department

University/organization

2. Details of the research project

Title of project/project number (if any)

Short description of the research project for which data and/or samples are requested, including a summary of planned analyses

Description of amount and type of biological samples and/ or data requested:

TURN OVER, PLEASE

Describe the desired characteristics of the study subjects:

3. Signatures
Signature of the applicant PI Name, printed clearly

4. Availability of data and/or samples (to be filled in by LifeGene):

Requested data available Yes No Comment to availability and possible alternatives (if applicable)

Requested samples available Yes No

Comment to availability and possible alternatives (if applicable)

5. Invitatation to main application

Invited to submit main application to LifeGene Yes No (see reason) Reason for declining the application

Date and Signature, Chief Executive Officer of LifeGene

Name, printed clearly