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Request an MTA (Outgoing)

Should you wish to send materials to another researcher, you require an MTA. At Western, the RD&S Contracts Research group prepares MTAs. Western researchers (including Robarts) may submit the following form to request assistance with creating an MTA, and they may contact Goretti Fordyce, Agreements Coordinator, 519-661-2111 ext 80180 with any questions. Contact Goretti Fordyce directly if you require assistance with an MTA for incoming materials.

The MTA contact for Lawson is Todd Copeland, Manager, Technology Development & Commercialization, 519.685.8500, ext. 77722.

1. Principal Investigator's Contact Information

First name* Last name*

Email*

Phone Number Fax

Institution

Department

Title

Office Address

2. Recipient Information

Name of Recipient Scientist

Title

Phone Fax

Address

Recipients' Deptartment / Organization / Company

3. Description of Material

What is the material you will be providing?

Was the Material created using another material obtained from a third party(ies)?

Yes No

If so, is that material transferred under an agreement?

Yes No

Please provide details:

Was the Material created as part of a research project for which you received industrial and/or government funding?

Yes No

If yes, please provide details:

4. Intellectual Property and Publications Is the Material related to an invention?

Yes No

If yes, please provide details:

Have you already disclosed the technology to WORLDiscoveries™?

Yes No

Do you think that information regarding the Material and the use of it should be kept confidential?

Yes No

Would you like to have a report summarizing the research results regarding the use of Material from the Recipient scientist?

Yes No

If the Recipient scientist is going to publish research results regarding the use of Material, would you like to review on the publication in advance?

Yes No

5. Other Is an export license required for the Material?

Yes No

Is the Material a live animal strain, or derived from an animal, or a human sample, or a drug?

Yes No

(Note: Please check with relevant departments/facilities if the Material is a live animal or is derived from an animal source)

If the material is human tissue or blood samples please provide the Research Ethics Board (REB) number:

If animal research is involved please provide the Animal Use Protocol (AUP) number:

Who is paying for the cost of providing the Material?

Please add any additional information that you believe to be pertinent:

Request an MTA (Outgoing)

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