First name*   Last name*

Email*

Phone Number Fax

Institution University of Western Ontario Lawson Health Research Institute Robarts Research Institute

Department

Title

Office Address

Please provide contact information for the co-applicant of this NDA (if applicable). This person will be added to the Agreement as a designated representative.

Name  

Email

Phone Number Fax

Institution University of Western Ontario Lawson Health Research Institute Robarts Research Institute

Department

Title

Office Address

May we contact your co-applicant regarding this NDA request if we cannot reach you?
Yes No

Please list any other co-applicant(s) for this NDA. These people will be added to the Agreement as designated representatives.

Organization's Full Legal Name

Organization's Complete Address

Organization's Signing Authority (Individual who can bind the organization in a legal agreement)

Title of Signing Authority (e.g. CEO, Director)

Contact's Name Title

Contact's Phone Fax

Contact's Email

Please list any other contacts you have at this organization, related to this NDA

What does the information relate to? (e.g. research project, technology title)

To enable the recipient to assess the technology for potential use
To enable the recipient to evaluate a potential research collaboration
Other

If other, please provide details:

Yes No

If yes, please provide details:

Yes No

If yes, please provide details (i.e. date of disclosure and contact person). If not, when do you expect to disclose.