Materials Transfer Agreement (MTA) Form

Funding Source

Internal FundsGrantedOther

Name of Fund

OSP or Grant #

Other:

Please indicate if you are:

Receiving materialsSending materials

Sending related data to the material

Receiving related data to the material

PI Name

PI Email

Lab Coordinator Name

Coordinator Email

Department

Contact Phone Number

Lab Address

Collaborating Institution/Company Name

Institution/Company Contact Phone Number

Institution Country

United StatesSomewhere else

Street Address

Address Line 2

City

State

ZIP Code

Full Address, Including Country

Collaborator Name

Collaborator Email

Contract Negotiator Name

Contract Negotiator Email

Is the material being imported (received) from outside the United States?

Yes

(Import permit verification is the PI's responsiblity prior to authorizing shipment)

Resources:
U.S. Customs and Border Protection

CDC Import Permit Program (IPP)

Penn State U.S. Customs Broker

Is the Material being received at a location other than PI’s Lab? (i.e. Comp. Med)

YesNo

If Yes, please enter Receiving Point of Contact and Address:

What work will be done by the additional party?

Has the Institutional Review Board (IRB) been contacted?

YesNo

Please provide your IRB Study #

Material is or contains human stem cells?

Yes

Does the material contain embryonic stem cells?

Yes

Does the material contain induced pluripotent stem cells?

Yes

Has the Embryonic Stem Cell Research Oversight (ESCRO) Committee been contacted?

Yes

Contact Email Address/Phone for Additional Party

What work will be done by the additional party?

(Export Control Approval is required before MTA processing)

If sending dangerous, hazardous, or human-derived material, has the Biosafety and Recombinant DNA Committee (BRDC) / Institutional Biosafety Committee (IBC) been contacted?

Yes

Please provide your BRDC or IBC Study #

Do you consider the outgoing material proprietary or to have potential commercial value?

Yes

Has an invention disclosure been filed?

Yes

List Tech ID# or Title

Do you need reimbursement for the cost of production or transfer of the material?

Yes

Amount of Reimbursement