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? |
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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.
|
________________________________________________________________
Organization
|
|
________________________________________________________________
Signature
|
|
________________________________________________________________
Name of Individual Authorized to Enter into this
Agreement
|
|
________________________________________________________________
Title
|
|
________________________________________________________________
Date
|
This section to be filled in by NCI personnel only:
AGREED: National
Cancer Institute
|
________________________________________________________________
Signature
Director, NCI
|
________________________________________________________________
Date
|
To send your application and test data forms
by regular mail:
Licensing and Distribution Program
Office of Communications
National Cancer Institute
6116 Executive
Blvd, Suite 300
Bethesda, MD 20892-8321
Fax: 301-480-8105
e-mail: license@cips.nci.nih.gov
|
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