Human Tissue Transfer Agreement Application
1. Applicant Information
Full Name
Institution/Organization
Position/Title
Address
Email Address
Phone Number
2. Recipient Information
Recipient Name
Recipient Institution/Organization
Recipient Address
Recipient Email
Recipient Phone
3. Human Tissue Details
Type of Tissue
Description (Source, Quantity, Identification, etc.)
4. Purpose of Transfer
Research/Clinical Purpose
5. Ethical/Legal Approval
Describe Ethical or Legal Approval (IRB, Consent, etc.)
6. Transport and Handling
Transport Method and Precautions
7. Agreement
I declare that the above information is accurate and complete.