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REQUEST EMBARC-BRIDGE SAMPLES
Application to Access EMBARC-BRIDGE Samples
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Name
*
First
Last
Institution / Organisation
*
Position
*
Contact Number
Email
*
and of Date
Date of Request
*
Disclosure and conflicts of interest:
*
Please disclose any potential conflicts of interest and associations with private companies, especially pharmaceutical companies. Conflicts should be disclosed even where the applicant considers these not to be relevant to the present application.
Data / information requested:
*
Title, AIM and brief description of the project, activity or purpose for which the requested EMBARC-BRIDGE samples will be used.
List intended uses of the data or information:
*
(incl. anticipated publications, reports, presentations, analyses etc).
Funder (please state sources of funding, or state project not funded):
*
Is statistician support requested for this study?
*
Date required (if relevant):
Submit
