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Request and Agreement Form for the Distribution of
Japanese-origin B Cell Lines
To
Form A-3
purified DNA from
Japan Health Sciences Foundation, Health Science Research Resources Bank
1. I hereby request the distribution of purified DNA from Japanese-origin B cell lines.
Date of receipt:
Date of application:
No.:
Name and title of applicant (in print):
Tel:
Fax:
E-mail:
Name and address of institution:
Name of laboratory and responsible person:
Samples ordered (description, quantity, etc)
Research purposes:
2. I agree to comply with the following stipulations when I receive the distribution
service of specimen ordered from Human Science Research Resources Bank (henceforth
abbreviated as HSRRB).
1) The research project that will use the samples ordered has been approved by the
Institutional Review Board of our institute. I will not use the DNA in unethical
experiments such as direct administration to humans.
2) I fully respect the priority of the person who established the B cell lines.
3) I will use the DNA only for research, testing, and educational purposes, and not for
military and direct profit-making purposes.
4) I will not impart the DNA to a third party.
5) I will not ask HSRRB to be responsible for any accident or loss incurred from the
use of the DNA.
6) When I publish any results obtained from the use of the DNA, I will state the
procurement of the DNA from HSRRB.
Signature of applicant: