Application form
Human cellular material

Name of researcher : 	     
Research center :        
E-mail :       	
Phone :        
Fax :        	

•	PROJECT TITLE :      

Please add a detailed scientific abstract (Word document). Your project will be evaluated by the scientific committee of the BCLQ. The researcher and his/her collaborators must be clearly identified.

•	FUNDING :      	
Grant number :      
Start and end dates :      
Total amount of the grant :    $      

•	NUMBER AND TYPE OF SPECIMENS REQUIRED :  
	 
 	Type of hematologic cancer :      

Number of specimens :                                                    DMSO :       		   Trizol :      
 
•	PROJECT APPROVAL BY YOUR ETHICS BOARD :  *          
	
*	Prior approval applicable for the year in progress shall be required by the researcher’s ethics board to use cells secured from the BCLQ for the purposes of this project. Proof of ethics certification must accompany this application.
*	The researcher will have to sign a cellular material transfer agreement.
*	All documents must be identified (name, date, title of document) and emailed to Mr. François Béliveau, coordinator of the BCLQ : bclq@ssss.gouv.qc.ca   

	 
SIGNATURE OF RESEARCHER						            Date