APPLICATION FORM
for Request of Samples from NHLBI PEGT Hematopoietic Cell Processing Core (PEGT-HCPC)
(THIS FORM IS FOR VIEWING ONLY - THIS FORM IS NOT FUNCTIONAL)
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Date
Principal Investigator
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First Name:
M.I.
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Last Name:
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Room/Suite:
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Street Address:
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City:
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Phone Number:
Ext:
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Fax Number:
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PEGT Grant Number :
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PEGT Grant Title :
Brief description of studies proposed in Grant (may use Grant Abstract):
(up to 350 words)
Brief description of how requested cells will be utilized for this research, including a short description of experimental protocols and procedures:
(up to 100 words)
Specify the type of cells and the amounts you will be requesting:
Human
G-CSF mobilized PBSC, CD34 enriched
# vials
(each vial contains(cryopreserved) 5-10 million cells)
Cadaveric Bone Marrow, CD34 enriched
# vials
(each vial contains(cryopreserved) 5-10 million cells)
G-CSF mobilized PBSC B not enriched
# bags
(each bag contains(cryopreserved) 5-10 billion nucleated cells)
Cadaveric Bone Marrow B not enriched
# bags
(each bag contains(cryopreserved) 5-10 billion nucleated cells)
G-CSF mobilized PBSCB CD34-flow thru
# bags
(each bag contains(cryopreserved) 5-10 billion nucleated cells)
Cadaveric Bone MarrowB CD34-flow thru
# bags
(each bag contains(cryopreserved) 5-10 billion nucleated cells)
Special Request (human cells only): Specify type of starting cells and type of cell selection (e.g. CD3, CD4, CD8, CD14 etc.) required.
Primate
Baboon (Papio cynocephalus) OR
Pig-Tailed Macaque (Macaca nemistrina)
G-CSF mobilized PBSC, CD34 enriched
# vials
(each vial contains(cryopreserved) 2-5 million cells)
G-CSF mobilized PBSC B not enriched
# bags
(each bag contains(cryopreserved) 5-10 billion nucleated cells)
G-CSF mobilized PBSCB CD34-flow thru
# bags
(each bag contains(cryopreserved) 5-10 billion nucleated cells)
(THIS FORM IS FOR VIEWING ONLY - THIS FORM IS NOT FUNCTIONAL)
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