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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