Specimens requested from the
______________________________________ Study
Number of specimens required: ___________
Description of the
characteristics of the specimens required
(demographic
information)
I agree to comply with all standards and restrictions
as specified in this document. I have completed the Standard Indemnification
Agreement or the State Institution Compliance Agreement, or the Waiver of
Indemnification Agreement.
_____________________________ Requestor
(Signature)
_____________________________ Printed Name
_____________________________ Date
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