GLOBAL HEALTH INNOVATIVE TECHNOLOGY FUND DRUG DISCOVERY SCREENING PLATFORM RFP2014-002 Contact Form Please fill out the following information and submit by email to (please use email subject: “Potential Screening Platform 2014-002”). Questions specific to this Screening Platform can only be answered with the submission of this information. Partner 1 Partner 2 Organization Name Organization Type (e.g., PDP, pharma company, academic institution) Japanese Japanese Organization Status Non-Japanese Non-Japanese Name of Contact Person (Nominate one person from partners as a main contact Main Contact Point Main Contact Point point with the GHIT Fund) Title Email Address Direct Phone No. Cell Phone No. Fax No. Tuberculosis Malaria Disease of interest Chagas disease (check all that apply) Leishmaniasis Please provide an approximated amount needed to fund your project. Insert budget in USD
GLOBAL HEALTH INNOVATIVE TECHNOLOGY FUND DRUG DISCOVERY SCREENING PLATFORM RFP2014-002 Contact Form Please fill out the following information and submit by email to (please use email subject: “Potential Screening Platform 2014-002”). Questions specific to this Screening Platform can only be answered with the submission of this information. Partner 1 Partner 2 Organization Name Organization Type (e.g., PDP, pharma company, academic institution) Organization Status Japanese Non-Japanese Japanese Non-Japanese Name of Contact Person (Nominate one person from partners as a main contact point with the GHIT Fund) Main Contact Point Main Contact Point Title Email Address Direct Phone No. Cell Phone No. Fax No. Disease of interest (check all that apply) Tuberculosis Malaria Chagas disease Leishmaniasis Please provide an approximated amount needed to fund your project. Insert budget in USD
GHIT%20RFP%20Screening%20Plartform%202014-002%20Contact%20Form.docx