CTSU Supply Request Form

Attachment_A07_supply
Attach_1ff_CTSUSR

OMB# 0925-0753
Expiration Date: 07/31/2021

Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a
person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974,
Bethesda, MD 20892-7974, ATTN: PRA (0925-0753). Do not return the completed form to this address.

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OMB# 0925-0753
Expiration Date: 07/31/2021

Attachment_A7_supply
Attach_1ff_CTSUSR

1441 West Montgomery Ave WB 410S Rockville, MD 20850-2062 1-888-823-5923 FAX 1-888-691-8039

CTSU Supply Request Form:
upload the form to the Regulatory Submission

To request supplies from CTSU, please complete the information below and faxPortal.
this form
to the
Data Center at
Select
theCTSU
Membership/Supplies
document
1-888-691-8039. Following review and approval of this application, the requested item will be mailed to the address you
type at www.ctsu.org and select the membership/
provide below. Please allow 7-10 business days for processing and mailing of supply requests.

supply document type.

Protocol Number (s)
Item Requested
Number Requested
Contact Name
Institution Code
Office
Street 1
Street 2
Add. 1
Add. 2
City
State
Zip
Phone
Fax
E-mail
Shipping preference Select one:
Fed Ex
Provide account number:
U.S. Mail
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CTSU
Internal
Reminders:
Internal
use only:
Verify the site registration status is active Set
Site registered
for protocol?
Y tracking
N (site# must be registered to ship supplies)
Packet
to complete
and add FedEx
to the comments if applicable
Date of shipment? ____________
Comments: ____________________________
Method of shipment? ___________

July_2018
Revised_July_2015
6/04/04 –by
mCTSU
heringfor local reproduction
Authorized

Track Number if Fed Ex__________________