-Basic Information 1. Principal Investigator: 2. Department/Institute/Center that will Department/Institute/Center Name: be administratively responsible for Department/Institute/Center ID: this Agreement: 4. Title of Submission: 5. Department Administrative Contact for PI Name: Contracting Party Information 1 Contracting Name: 2. Legal Contact Name: 3. Legal Contact E-Mail Address: 4. Legal Contact Phone Number: 5. Scientific Contact Name: 6. Scientific Contact E-mail: 7. Does the Principal Investigator have a Yes financial relationship with any of the No Contracting Parties listed above that is or should be disclosed on your If Yes, please explain: University of Pittsburgh Conflict of Interest disclosure form? Material Information 1. Identify all materials shared under this MTA: 2. Do these contain biological material? Yes No 3. Is the material commercially Yes available? No Material Source Information 1. Was all material independently Yes developed by you or under your No direction at Pitt? If no, please explain: 2. Does the material incorporate or is Yes the material derived from materials No obtained from a If Yes, please explain: Third party? 3. Was any of the material brought to Yes Pitt from somewhere else? No If Yes, please explain: 4. Are there alternative sources to Yes provide the material? No If Yes, please explain:
-Basic Information 1. Principal Investigator: 2. Department/Institute/Center that will be administratively responsible for this Agreement: Department/Institute/Center Name: Department/Institute/Center ID: 4. Title of Submission: 5. Department Administrative Contact for PI Name: Contracting Party Information 1 Contracting Name: 2. Legal Contact Name: 3. Legal Contact E-Mail Address: 4. Legal Contact Phone Number: 5. Scientific Contact Name: 6. Scientific Contact E-mail: 7. Does the Principal Investigator have a financial relationship with any of the Contracting Parties listed above that is or should be disclosed on your University of Pittsburgh Conflict of Interest disclosure form? Yes No If Yes, please explain: Material Information 1. Identify all materials shared under this MTA: 2. Do these contain biological material? Yes No 3. Is the material commercially available? Yes No Material Source Information 1. Was all material independently developed by you or under your direction at Pitt? Yes No If no, please explain: 2. Does the material incorporate or is the material derived from materials obtained from a Third party? Yes No If Yes, please explain: 3. Was any of the material brought to Pitt from somewhere else? Yes No If Yes, please explain: 4. Are there alternative sources to provide the material? Yes No If Yes, please explain:
Outgoing%20Material%20Transfer%20Agreement%20Submission%20Form.MYRA_.3-15-15.docx