New License/Distributor Application

Please complete this form and return it to:
OC Licensing - fax: (301) 480-8105 or e-mail: license@cips.nci.nih.gov
To send your application by regular mail, see the address listed at the end of these forms.
If you have any questions regarding this application, call (301) 496-1277.
Thank you.

All information is for internal use only and will be kept confidential.

Date: ________________

Name of organization: _____________________________________________

Division/department: ______________________________________________

Type of organization: ____Profit ____Nonprofit

Customer mailing address:
(Contact information for customers to subscribe to your service, etc.).

___________________________________________________________

___________________________________________________________

___________________________________________________________

Customer phone: ________________ Customer fax: _________________

Customer E-mail address: ______________________________________

Website URL: ________________________________________________

Business contact: ________________________________________________

Address: ___________________________________________________

___________________________________________________________

Phone: _______________________ fax: __________________________

E-mail address: ______________________________________________

Technical contact: _______________________________________________

Address: ___________________________________________________

___________________________________________________________

Phone: _____________________ fax: ____________________________

E-mail address: ______________________________________________

Briefly describe your organization (2-3 sentences):

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

1.	Please provide a detailed description of your service(s) or product(s) that will include NCI information (attach a separate document -- business plans are acceptable).

2.	How do you plan to distribute your products/services that will include NCI information?Check all that apply.

( ) CD-ROM ( ) E-mail ( ) World Wide Web ( ) Print: please specify: __________________________________ ( ) Other: please specify: _________________________________

3.	Who are the target audiences for your products/services that will include NCI information?Check all that apply:

( ) Attorneys ( ) Biomedical Professionals ( ) Business Professionals ( ) Dental Patients ( ) Dentists ( ) Educators ( ) General Public ( ) Health Professionals ( ) Healthcare Professionals ( ) HMOs

( ) Hospitals ( ) Medical/Faculty/Students ( ) Medical Libraries ( ) Nurses ( ) Patients/Families ( ) Pharmacists ( ) Physicians ( ) Researchers ( ) Scientists ( ) Universities

( ) Other: ___________________________________________________

4.	Are these audiences end-users of the information? If not, please describe in detail:

__________________________________________________________

__________________________________________________________

__________________________________________________________

5.	How do you plan to promote your products/services that will include NCI information?

__________________________________________________________

__________________________________________________________

__________________________________________________________

6.	Will your product/service that includes NCI information contain advertising? If so, what types of products will be advertised? Where will the advertising be placed in relation to NCI data?

__________________________________________________________

__________________________________________________________

__________________________________________________________

7.	What price will you charge for your products/services that include NCI information, if applicable? (If more than one product/service, please specify price of each.)

__________________________________________________________

__________________________________________________________

__________________________________________________________

8.	How will NCI data be updated within your products/services?

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

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9.	Are you able to provide statistics on:

the number of page views? ( ) Yes ( ) No

the number of user sessions? ( ) Yes ( ) No

the number of users? ( ) Yes ( ) No

other information? Please describe: __________________________________

10.

What is your target date for launching this product/service that will include NCI information?

__________________________________________________________ __________________________________________________________ We would like to include the materials noted below in your file. Please include these items when you submit this application: Other materials that are relevant to your licensing/distribution request Corporate brochure/annual report/and other materials about your organization Promotional materials (that promote your products that will include NCI information)

Send materials to:

Licensing and Distribution Program

Office of Communications

National Cancer Institute

6116 Executive Blvd, Suite 300

Bethesda, MD 20892-8321

NCI Licensing and Distribution Program Test Data Agreement for NCI Cancer Information Databases

Complete this form and return with your completed license application. The undersigned requests test file(s) containing data used to create the National Cancer Institute's information database, PDQ®. Upon receipt of the file(s), the undersigned agrees that the file(s) will be used exclusively to examine the structure and content of the database and that neither the file(s) nor the data in the file(s) will be made available to any other organization or individual for any purpose. The undersigned also agrees to acknowledge receipt of the file(s), and to destroy the file copy(s) and all data obtained through use of the file(s) (including derivative files or printouts) within one month after the PDQ® database becomes available for distribution under a standard licensing agreement or 6 months from the date of this Test Data Agreement. If, prior to finalizing a license agreement, the undersigned wishes to demonstrate to the public the product developed with the test file(s), the undersigned agrees to: 1. sign a Demonstration Agreement, and 2. make the demonstration version available to the NCI for review at least one month prior to the public demonstration. No representations or warranties, express or implied, including any implied warranty of merchantability or fitness for a particular purpose, with respect to the test file(s) or the data on them are made by Provider.

Licensing Partners

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