Page One: Recipient Information

The Developmental Therapeutics Program makes available small amounts of non-discreet compounds for research purposes to investigators world-wide. The researcher should determine the requirements of the research, then request the minimum amount of each compound. Although there is no fee for each sample, we do require recipients to cover shipping charges with a Federal Express account number. These samples are not available for human use or for use in food producing plants or animals. Please note that only a very small number of the compounds have been analyzed by the NCI, therefore, we do not know the purity and/or structural integrity of most samples.

Page 1: RECIPIENT Information: Please provide all information requested in the fill-in form:

Academic Researchers Please Note! A Simple Letter of Agreement must be agreed to in order to place this order. Most Universities DO NOT confer signatory authority to individual investigators. Please contact your administrative/technology transfer office before filling out this information to determine who has signatory authority for your institution.

Download an example copy of the Simple Letter of Agreement in Microsoft Word or Adobie PDF

Items marked * are required
Primary Contact Information:
Full Name, Title and Street Delivery Address of Recipient Scientist
Salutation
First Name *
Last Name *
Institution (primary affiliation): *
E-mail address at primary institutional affiliation: *
Address of Institution: *
Mail Stop:
City: *
State/Province: *
Country *
Postal/Zip code:
Type of Affiliation *
U.S. Government
University
Non-profit Organization
For-Profit
All Others
Telephone Number *
FAX Number
Description of Assay or Research *

Federal Express Account Number (Enter as a single 9 digit number. Do not add spaces or other characters)
Federal Express Account # : *
Internal Billing # : (If Applicable)