ࡱ                >  	               Z          \          Y    '`	               E$   bjbj{P{P                  	 <H  : : .                                                                                                                        X      X      X  8     D     D         Q/  &  $  H  l      l      l      l      G         L   !  (   |&     ~&      ~&      ~&  4   &    *    .  $   w0  h  2  ^   .                           ,"                      G       G       ,"      ,"      .                          l              l     /     <%      <%      <%      ,"           l            l      |&              <%                                                      ,"      |&              <%              <%                                                                          <%      l           _]h        X      "  r  <%              %     !/  0   Q/      <%      =3       $     =3      <%                                                                              =3                    <%  d   ?!  "   a!     <%      y!     !                                     ?!      ?!      ?!      .      .                                      $  X                                   ?!      ?!      ?!      Q/      ,"      ,"      ,"      ,"                              T                      T                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   	MATERIAL TRANSFER AGREEMENT REQUEST	Material Transfer Agreements (MTAs) protect the Universitys intellectual property rights in materials youve created and indicate what the recipient can and cant do with them.  They should routinely be used whenever youre sending out something unique that you have created (e.g. genes, proteins, hybridomas, crystallographic data, compounds, semiconductors, software etc.), whether to a company or another academic researcher.  The information on this form will allow us to quickly get a signed MTA in place.  When it is, we will notify you that the material(s) requested may now be sent.  Please fax or email a signed pdf copy of the completed form to Sara Sikorski at the Office of Technology Transfer and Licensing at 2-6981 or  HYPERLINK "mailto:sikorsk@bc.edu" sikorsk@bc.edu, respectively.  Call 2-1682 with any questions. BC ProviderName:	________________________________________		Email:  ____________________Phone:	________________________________________		Fax:	____________________College/Lab:	________________________________________		Lab Chief Signature: ___________________________________  		Date:  _____________________RequestorName:	________________________________________	Phone:	______________Institution:	________________________________________	Fax:	______________Address:	________________________________________	Email: 	_____________	________________________________________	________________________________________Materials	_______________________________________________________________Requested	_______________________________________________________________Intended	_______________________________________________________________UseFor Transfer of Mice:	Strain Name:_________________________________	Name and function of gene:  ______________________________________	Intended use:   		 FORMCHECKBOX  For experimental use only (no breeding)	 	 FORMCHECKBOX  For breeding and experimental use in a research institution 		 FORMCHECKBOX  For breeding and commercial use (e.g. resale of animals, or sale of their offspring or products derived from this strain)	 	 FORMCHECKBOX  Other (describe) :  ____________________________________________		To recover costs, industrial users are usually charged a standard fee of $2,000.  Should we request this fee in this case?        Yes___   How Much? ______  No___   Export of Materials ChecklistExport control laws are federal regulations that define the conditions under which certain information, technologies, and commodities can be transmitted to individuals overseas (including U.S. citizens).  If you are shipping materials overseas, the materials may be subject to federal regulation.  Please determine if the following criteria are met: FORMCHECKBOX Item will not be shipped to or through the Balkans, Burma, Cte dIvoire, Cuba, Iran, Iraq, Liberia, Libya, North Korea, Sudan, Syria or Zimbabwe and services will not be provided in any of these countries FORMCHECKBOX Item is not designed or adapted for a military application and does not relate to and will not be used in connection with weapons of mass destruction or terrorism FORMCHECKBOX The intended recipient is not on any the following lists:	- The Denied Persons List:   HYPERLINK "http://www.bis.doc.gov/dpl/Default.shtm" http://www.bis.doc.gov/dpl/Default.shtm	- The Unverified List:   HYPERLINK "http://www.bis.doc.gov/Enforcement/UnverifiedList/unverified_parties.html" http://www.bis.doc.gov/Enforcement/UnverifiedList/unverified_parties.html	- The Specially Designated Nationals List:   HYPERLINK "http://www.treas.gov/offices/enforcement/ofac/sdn/" http://www.treas.gov/offices/enforcement/ofac/sdn/	- The Entity List:   HYPERLINK "http://www.bis.doc.gov/Entities/Default.htm" http://www.bis.doc.gov/Entities/Default.htm	- The Debarred List:   HYPERLINK "http://pmdtc.org/debar059.htm" http://pmdtc.org/debar059.htm FORMCHECKBOX No red flags from the Department of Commerce Red Flag list are present.	 HYPERLINK "http://www.bis.doc.gov/Enforcement/redflags.htm" http://www.bis.doc.gov/Enforcement/redflags.htm FORMCHECKBOX The material to be transferred does not appear on the Commerce Control List ( HYPERLINK "http://www.access.gpo.gov/bis/ear/ear_data.html" http://www.access.gpo.gov/bis/ear/ear_data.html) or the U.S. Munitions List ( HYPERLINK "http://fas.org/spp/starwars/offdocs/itar/p121.htm" http://fas.org/spp/starwars/offdocs/itar/p121.htm).  Summaries of the categories of materials covered by these lists are below.  You should review the entire list(s) online if the material you plan to transfer fits within one of the categories.  If you are unable to confirm any of these statements or have any questions contact Steve Erickson, Director, Office of Research Compliance at 2-3345 or  HYPERLINK "mailto:ericksst@bc.edu" \o "" \t "_self" ericksst@bc.edu I certify that I have undertaken any investigation necessary to answer these questions and have answered these questions truthfully to the best of my knowledge._____________________________________		_____________________Signature							DateName (printed):  ________________________________________________________Commerce Control List HYPERLINK "http://www.access.gpo.gov/bis/ear/ear_data.html" http://www.access.gpo.gov/bis/ear/ear_data.htmlCategory 0 - Nuclear Materials, Facilities & Equipment (and Miscellaneous Items) Category 1 - Materials, Chemicals, Microorganisms, and Toxins Category 2 - Materials Processing Category 3 - Electronics Category 4 - Computers Category 5 (Part 1) - Telecommunications Category 5 (Part 2) - Information Security Category 6 - Sensors and Lasers Category 7 - Navigation and Avionics Category 8 - Marine Category 9 - Propulsion Systems, Space Vehicles and Related EquipmentMunitions List HYPERLINK "http://fas.org/spp/starwars/offdocs/itar/p121.htm" http://fas.org/spp/starwars/offdocs/itar/p121.htmCategory I Firearms Category II Artillery Projectors Category III  Ammunition Category IV  Launch Vehicles, Guided Missiles, Ballistic Missiles, Rockets, Torpedoes, 	Bombs and Mines Category V  Explosives, Propellants, Incendiary Agents, and Their Constituents Category VI  Vessels of War and Special Naval Equipment Category VII  Tanks and Military Vehicles Category VIII  Aircraft, [Spacecraft] and Associated Equipment Category IX  Military Training Equipment Category X  Protective Personnel Equipment Category XI  Military [and Space] Electronics Category XII  Fire Control, Range Finder, Optical and Guidance and Control Equipment Category XIII  Auxiliary Military Equipment Category XIV  Toxicological Agents and Equipment and Radiological Equipment Category XV  Spacecraft Systems and Associated Equipment Category XVI  Nuclear Weapons Design and Test Equipment Category XVII  Classified Articles, Technical Data and Defense Services Not Otherwise 	Enumerated Category XVIII  [Reserved] Category XIX  [Reserved] Category XX  Submersible Vessels, Oceanographic and Associated Equipment Category XXI  Miscellaneous Articles                                                                                                                                                                                                                                                                                                                                                                                                                                                                %  &  '  :  C  J      
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   p @   $ @a$
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   `'ABgd4HT     .$  D$                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                p  z  {          J  N  O              v  x            f  g  u  v  w                  վȴȧȖȂȖnȖ                                         'j3  h4HT hV CJ OJ QJ U'j   h4HT hV CJ OJ QJ U!j    h4HT hV CJ OJ QJ Uh4HT hY> CJ OJ QJ  hxa CJ OJ QJ  hG CJ OJ QJ  h4HT hV CJ OJ QJ  h4HT h, CJ OJ QJ  h4HT hC\U >*CJ OJ QJ h: h, 5>*CJ OJ QJ #  D  E              .  8  y  z            R  d                                                                                                                                                                                                                                                                                                                                                           T@	`^	``gdV   gdV                              m             ͹ͬxk^TF<                          h: CJ OJ QJ  j    h: CJ OJ QJ UhY> CJ OJ QJ  h4HT hY> CJ OJ QJ  h4HT h4HT CJ OJ QJ  h4HT h}^ CJ OJ QJ  h: h: 5CJ OJ QJ hV 5CJ OJ QJ h: hV 5CJ OJ QJ h4HT h, CJ OJ QJ  'j  h4HT hV CJ OJ QJ Uh4HT hV CJ OJ QJ  !j    h4HT hV CJ OJ QJ U'j  h4HT hV CJ OJ QJ U                                                                                                                         o                                                                    S  kd  $$If    0 -)                                      
t    6                            4   4 
 a  	  $If   gdV    gdV    $a$gd4HT    # $d %d &d 'd N    O    P    Q                                                  5  6  7  ^  _  y  z            ӲӞƍyjƍVj   'j&  h4HT h: CJ OJ QJ Uh4HT h: 0J CJ OJ QJ  'j  h4HT h: CJ OJ QJ U!j    h4HT h: CJ OJ QJ U'j  h: h, CJ OJ QJ U'j  h: h, CJ OJ QJ Uh4HT h: CJ OJ QJ  h: CJ OJ QJ  j    h: CJ OJ QJ U'j  h: h, CJ OJ QJ U !        `      @                                                                                                                                                                                                                                                                          	  $If   gd: 	  $If   gdV  S  kd
  $$If    0 -)                                      
t    6                            4   4 
 a     K  L                      >  ?  W  X                            B  C  D  s  t  kW'j  h4HT h: CJ OJ QJ U'j  h: h, CJ OJ QJ Uj    h: CJ OJ QJ Uh: CJ OJ QJ  'j)
  h4HT h: CJ OJ QJ U'j	  h4HT h: CJ OJ QJ Uh4HT h: 0J CJ OJ QJ  'j  h4HT h: CJ OJ QJ U!j    h4HT h: CJ OJ QJ Uh4HT h: CJ OJ QJ "        u  v                                                      E                                                    S  kdR  $$If    0 -)                                      
t    6                            4   4 
 a  	  $If   gd: 	  $If   gdV  S  kd  $$If    0 -)                                      
t    6                            4   4 
 a   t  v  w                    D  E  c  d              $            7  ǶǢǶuhYJ    hD hxa CJ OJ QJ ^J  hD hV CJ OJ QJ ^J  h4HT hV CJ OJ QJ  hE7 CJ OJ QJ  'j  h4HT h: CJ OJ QJ Uh4HT h: 0J CJ OJ QJ  'jY  h4HT h: CJ OJ QJ U!j    h4HT h: CJ OJ QJ Uh4HT h: CJ OJ QJ  'j  h: h, CJ OJ QJ Uj    h: CJ OJ QJ Uh: CJ OJ QJ           "  #  `  u  v    G  H          .                                                                                                                                                                                                                              $a$gd:    gd:    gdV  S  kd  $$If    0 -)                                      
t    6                            4   4 
 a   7  8  m  n  }  ~      u  v              E  F  G  &  '  յ{mW{G{m=                  hV CJ OJ QJ  h: hV 0J 5CJ OJ QJ *j^  h: hV 5CJ OJ QJ U h: hV 5CJ OJ QJ $j    h: hV 5CJ OJ QJ U h: hV 5>*CJ OJ QJ  h: CJ OJ QJ  h4HT hV CJ OJ QJ  hD hV CJ OJ QJ ^J   hD hxa 0J CJ OJ QJ ^J  %hD hxa B*CJ OJ QJ ^J ph333 .j    hD hxa B*CJ OJ QJ U^J ph333 .  X          &  '  (  7            V   h         !  \!  !  !  !  7"  d"  "  "  $#                                                                                                                                                                                                                                                                                                                                                         $a$gd:    gdV  '  (  7  8  w  x  y          .$  /$  1$  2$  4$  5$  7$  8$  :$  C$  D$  E$  Ϩ㚍}                                                                                                                                        hxa  h1r  j    h1r Uh4HT hV CJ OJ QJ  h4HT hV >*CJ OJ QJ h: hV 0J 5CJ OJ QJ -j  h: hV 5>*CJ OJ QJ U'j    h: hV 5>*CJ OJ QJ Uh: hV 5>*CJ OJ QJ  h4HT h: CJ OJ QJ $#  {#  #  #  #  $  -$  .$  0$  1$  3$  4$  6$  7$  9$  :$  ;$  <$  =$  >$  ?$  @$  A$  B$  C$  D$  E$                                                                                                                                                                                                                                                                                                                                                                              gdV  : P P &P :pY> / =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                         D                                                                y  K         s i k o r s k @ b c . e d u   y  K,   m a i l t o : s i k o r s k @ b c . e d u   t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         t   D                                                                    C h e c k 5                          $$If     !v h5 &5''#v &#v'':V  
t  0                                            6  5   4 
 t   D                                                               e     C h e c k 6                          $$If     !v h5 &5''#v &#v'':V  
t  0                                            6  5   4 
 t   D                                                                    C h e c k 7                           D                                                                y  K      (   h t t p : / / w w w . b i s . d o c . g o v / d p l / D e f a u l t . s h t m   y  KP   h t t p : / / w w w . b i s . d o c . g o v / d p l / D e f a u l t . s h t m     D                                                                y  K      J   h t t p : / / w w w . b i s . d o c . g o v / E n f o r c e m e n t / U n v e r i f i e d L i s t / u n v e r i f i e d _ p a r t i e s . h t m l   y  K   h t t p : / / w w w . b i s . d o c . g o v / E n f o r c e m e n t / U n v e r i f i e d L i s t / u n v e r i f i e d _ p a r t i e s . h t m l   A  D                                                                y  K      3   h t t p : / / w w w . t r e a s . g o v / o f f i c e s / e n f o r c e m e n t / o f a c / s d n /   y  Kf   h t t p : / / w w w . t r e a s . g o v / o f f i c e s / e n f o r c e m e n t / o f a c / s d n /   %  D                                                                y  K      ,   h t t p : / / w w w . b i s . d o c . g o v / E n t i t i e s / D e f a u l t . h t m   y  KX   h t t p : / / w w w . b i s . d o c . g o v / E n t i t i e s / D e f a u l t . h t m      D                                                                y  K         h t t p : / / p m d t c . o r g / d e b a r 0 5 9 . h t m   y  K<   h t t p : / / p m d t c . o r g / d e b a r 0 5 9 . h t m    $$If     !v h5 &5''#v &#v'':V  
t  0                                            6  5   4 
 t   D                                                               e     C h e c k 8                         5  D                                                                y  K      0   h t t p : / / w w w . b i s . d o c . g o v / E n f o r c e m e n t / r e d f l a g s . h t m   y  K`   h t t p : / / w w w . b i s . d o c . g o v / E n f o r c e m e n t / r e d f l a g s . h t m    $$If     !v h5 &5''#v &#v'':V  
t  0                                            6  5   4 
 t   D                                                               e     C h e c k 9                         5  D                                                                y  K      0   h t t p : / / w w w . a c c e s s . g p o . g o v / b i s / e a r / e a r _ d a t a . h t m l   y  K`   h t t p : / / w w w . a c c e s s . g p o . g o v / b i s / e a r / e a r _ d a t a . h t m l   =  D                                                                y  K      2   h t t p : / / f a s . o r g / s p p / s t a r w a r s / o f f d o c s / i t a r / p 1 2 1 . h t m   y  Kd   h t t p : / / f a s . o r g / s p p / s t a r w a r s / o f f d o c s / i t a r / p 1 2 1 . h t m    $$If     !v h5 &5''#v &#v'':V  
t  0                                            6  5   4 
 5  D                                                                y  K      0   h t t p : / / w w w . a c c e s s . g p o . g o v / b i s / e a r / e a r _ d a t a . h t m l   y  K`   h t t p : / / w w w . a c c e s s . g p o . g o v / b i s / e a r / e a r _ d a t a . h t m l   =  D                                                                y  K      2   h t t p : / / f a s . o r g / s p p / s t a r w a r s / o f f d o c s / i t a r / p 1 2 1 . h t m   y  Kd   h t t p : / / f a s . o r g / s p p / s t a r w a r s / o f f d o c s / i t a r / p 1 2 1 . h t m                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                <  @ <           N o r m a l       CJ _HmH	sH	tH	                  D A@ D          D e f a u l t   P a r a g r a p h   F o n t     V i@ V          T a b l e   N o r m a l     :V   4   4 
l a      ( k  (           N o   L i s t         L O  L           C o n t e n t s     $dh a$ 5CJ OJ QJ kH' 4 @ 4           H e a d e r      !   P O P           I n f o r m a t i o n      p @  OJ QJ kH'4  @ "4           F o o t e r      !   6 U@ 16   V   	 H y p e r l i n k    >*B*ph   F V@ AF   V    F o l l o w e d H y p e r l i n k    >*B*ph  j @ Sj   :   
 T a b l e   G r i d   7 :V 0                                       E    H        &   '   l  m  n  z  {          M  N  O              D  E              .  8  y  z            R  d              	  	  	  	  
  
                  `      @          u  v              "  #  `  u  v    G  H          .  X          &  '  (  7            V  h        \        7  d      $  {          -  .  0  1  3  4  6  7  9  :  ;  <  =  >  ?  @  A  B  C  F      0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                       0                        0                        0                        0                        0                        0                      0                      0                      0                      0                     0                      0                      0                      0                      0                      0                      0                      0                      0                      0                  @   0                      0                     0                      0                      0                     0                      0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                        0                       0                    @   0                   0 0                   @   0                   0 0                   @   0                   0 0                   @   0                   0 0                   @  0                   @  0                    @  0                    @  0                    @  0                    @  0                    @  0                    @  0                     0 0                    0 0                 9    &   '   l  m  n  z  {          M  N  z          	  	            `      @        u  v            H    &  (  7      -  F   0 0                    0 0                    0 0                    0 0                    00                    00                    00                    00                    00                    00                    00                    00                    00                    00               p 00                   X 0                 
X 0                     00                        0                     00                    00               RSh 0 0                   00               $SSh 0 0                  h 0 0                  j 0 0                  j 0 0                  j 0 0                  j 0 0                   00               SSh 00                  h 0 0                   0 0            !   <TSh 00                   0"0            #   tTSh 00                  X 0!             "   j 00                  j 00                  @   0                  j 00                 j 00                  j 00                  @   0                  j 0 0                   j 0 0                   j 0 0                       0                               	                                 p        t  7  '  E$                        "                .  $#  E$                    !   #      D$       *  9  f  v              
              6  ^  y      K          >  W            C  s  v        D  c      7  m  }      E  7  x    E  XG$G$G$G$G$G$G$XXXXXG$XG$XXXXX  8                         @                           0    (    	                    
          B    
        S              	   ?          	    C h e c k 1  C h e c k 2  C h e c k 3  C h e c k 4  C h e c k 5  C h e c k 6  C h e c k 7  C h e c k 8  C h e c k 9 g                 w  F                              w                  F      XF    XF   \
  \
  F           `
  `
  F            9      *urn:schemas-microsoft-com:office:smarttagsplace B      *urn:schemas-microsoft-com:office:smarttagscountry-region                      E   I   R  \      -  .  .  0  0  1  1  3  4  6  7  9  :  C  F                               6  >      t	  y	          q  ~          %  3  e  q              @  O  m             -  =                #  -  .  .  0  0  1  1  3  4  6  7  9  :  C  F   3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3  3                    K  {    L  O                	  	  (  7    -  .  .  0  0  1  1  3  4  6  7  9  :  C  F                                      -  .  .  0  0  1  1  3  4  6  7  9  :  F                                   S , E7 OA G 4HT C\U :Z d] }^ xa   O D 1r Y> / : V     %   E  	  
  
                      u  v        .  0  3  6  9  C  F                                                                        @Catherine's printer Ne05: winspool HP LaserJet 1020 C a t h e r i n e ' s   p r i n t e r                            4    
o    X  X                                                                                                                          SDDM    HP LaserJet 1020                                                                                                                               -                                                      (   d                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 C a t h e r i n e ' s   p r i n t e r                            4    
o    X  X                                                                                                                          SDDM    HP LaserJet 1020                                                                                                                               -                                                      (   d                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Q                     E  p   @      U n k n o w n                                   G  z                  T i m e s   N e w   R o m a n   5                       S y m b o l   3&  z                  A r i a l   ;"                        H e l v e t i c a   3                          T i m e s   "  1 h    mfmfHF    4         3   4        3       $                                                                                                                                                                                                                                                                                                                            4    d                                                                                  2Q                            HX    	 ?    OA     2                                 M a d e l i n e   H .   D a n i e l s  I V E S C A                                                                                                                                                                                                                                              Oh +'0   x                                               	           
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                                                                      !   "   #   $   &   '   (   )   *   +   ,   -   .   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   J   K   L   M   N   O   P   R   S   T   U   V   W   X   [   R o o t   E n t r y                                                 	           F            pd]h]          D a t a                                                         
                                     %         1 T a b l e                                                                                                /   =3      W o r d D o c u m e n t                                                                                        <H       S u m m a r y I n f o r m a t i o n                           (                                     I           D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        Q           C o m p O b j                                                                                           q                                                                                                                               
  	           F   Microsoft Office Word Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                                                                                                                                           