CCRC Analytical Services Request Form

Client Name

First

Last

PI/Manager Name

First

Last

Email

Telephone

Institution/Organization

Institution/Organization Type

Commercial

Academic/Government

Department

Mailing Address

Major Source of Non-CCRC Funding

NIH

NSF

DOE

OtherOther

Grant Number

Sample Type

Sample Source

Sample Names

Describe Scientific Background and Rationale for the Requested Services

Describe Services Requested

Intellectual Property

For analytical and characterization services conducted at the CCRC:

Data generated for a completed service request is the property of the client, regardless of institutional or industry affiliation.
Methods development completed by the CCRC for the completion of a service request is the property of the University of Georgia.

Fees

Fees for each project will be determined by Dr. Azadi upon discussion with investigators and will be tailored to each project depending on complexity and depth of data needed.

Intended Payment Method

Credit Card

Purchase Order

Wire Transfer

Add Purchase Order Number

Publication of Non-Proprietary Data

I agree to acknowledge the CCRC and its funding source** in any publications resulting from CCRC services and to list as co-authors those CCRC personnel that made significant intellectual contributions to the generation of data or the preparation of the manuscript.

**For medically related projects, use the following statement:

This research was supported through the NIH-funded National Glycoscience Resource, CCRC Service and Training (NIH grant no. R24GM137782) to Parastoo Azadi at the Complex Carbohydrate Research Center.

**For non-medical projects, use the following statement:

This work was supported by the U.S. Department of Energy, Office of Science, Basic Energy Sciences, grant number DE-SC0015662 to Parastoo Azadi at the Complex Carbohydrate Research Center.

Electronic Signature

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