GHIT Fund Drug Discovery Screening Platform Reference Number: GHIT-RFP-Screening-2016-002 Contact Form Please fill out the following information and submit by email to (please use email subject: “Potential Screening Platform 2016-002”). Questions specific to this Screening Platform can only be answered with the submission of this information. Partner 1 Partner 2 Choose one PDP: Organization Name DNDi GATB MMV Organization Type (e.g., PDP, pharma PDP company, academic institution) Japanese Non-Japanese Organization Status 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 (check all that apply) Chagas disease Leishmaniasis Please provide an approximated amount needed to fund your project [Please insert budget in Japanese Yen]. Please describe major objectives of your screening project. End-of-Document
GHIT Fund Drug Discovery Screening Platform Reference Number: GHIT-RFP-Screening-2016-002 Contact Form Please fill out the following information and submit by email to (please use email subject: “Potential Screening Platform 2016-002”). Questions specific to this Screening Platform can only be answered with the submission of this information. Partner 1 Partner 2 Organization Name Choose one PDP: DNDi GATB MMV Organization Type (e.g., PDP, pharma company, academic institution) PDP Organization Status Japanese Non-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 [Please insert budget in Japanese Yen]. Please describe major objectives of your screening project. End-of-Document
GHIT_RFP_Screening_Plartform_2016-002_Contact_Form.docx