Application for Request of an Excluded Select Toxin

Montana State University Transfre of Excluded Select Toxins is in accordance with 42 CFR § 73.

denotes required fields.

Recipient

Name The person who will receive and be responsible for the toxin.

Title

Organization

Address 1

Address 2

City

State

Zip /Postal Code

Country

Phone Number

Fax Number

Transferor

Name

Address 1

Address 2

City

State

Zip /Postal Code

Country

Toxin

Describe the Toxin Toxin name, amount to be transferred, and date of expected transfer

Proposed Use What is the proposed use of this toxin? Also, describe facilities/biosafety procedures and any relevant Biosafety protocols that have been approved by your Institutional Biosafety Committee.

Do you already have the requested toxin in your possession?

Yes

Have you ever received/requested this toxin in the past?

Yes

If you have received this toxin in the past, how often do you receive this toxin?

Will you be using the toxin for its intended purpose as you described above or are you planning to give the toxin to someone else?

Signature

I certify that this toxin will be used in accordance with 42 CFR 73 and I have a legitimate need (i.e., reasonably justified by a prophylactic, protective, bon fide research, or other peaceful purpose) to handle or use such toxin.

Date

Signature

I have read the application information, agree to the above terms and conditions, and verify that all above information is correct and current.

I Agree

I Disagree

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Application for Request of an Excluded Select Toxin

ORC Director

IACUC & IBC Project Manager

IRB Administrator

IRB

Biosafety Officer

Radiation Safety Officer

Export Control

JRL Lab Manager

Compliance Specialist & Interim Conflict of Interest Manager

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