Georgia Tech Research Corporation



Georgia Tech Research Corporation

Material Transfer Initiation Form- OUTGOING

Georgia Tech Provider Information

Principal Investigator: ____________________________________

Department/School: ____________________________________

Mail Code: ____________________________________

Phone: ____________________________________

Email: ____________________________________

Admin. Email: ____________________________________

Material Information

1. Name/Description of Material: _____________________________________________________________________

2. Has the Material been shipped before? □ YES □ NO

If YES, to whom, when, and what MTA ID (if known)? _______________________________________________

3. Please provide a concise statement of work for Recipients’ use of the Material:

_______________________________________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

4. Is the Material associated with an invention already disclosed to the □ YES □ NO

Office of Innovation Commercialization and Translational Research?

If YES, please provide the (IC)3 ID: ________

5. If NO, are there other reasons why you believe an MTA is necessary? □ YES □ NO

_______________________________________________________________________________________________

6. Please list all funding sources and OSP Project Numbers for the research in which the Material was created:

Sponsor: ________________________ Project No.: ______________ PeopleSoft No.: ______________

Sponsor: ________________________ Project No.: ______________ PeopleSoft No.: ______________

7. Was the Material (or any part of the Material) created by or purchased from □ YES □ NO

a third party, or generated in a lab other than your current facility at GIT?

8. Will the Material be shipped outside of the United States? □ YES □ NO

If YES, please visit

and complete the form for material transfers.

9. Is the Material human embryonic stem cells? □ YES □ NO

Recipient Information

Organization: ____________________________________

Technical Contact: ____________________________________

Email: ____________________________________

Administrative Contact: ____________________________________

Email: ____________________________________

Principal Investigator Certification:

I certify that the information I have provided is true and accurate; I will comply with any terms or conditions of any Material Transfer Agreement that may be executed.

Signature of Georgia Tech Principal Investigator Date

All shipments are handled through Environmental Health & Safety. Please contact EHS for packaging and shipment of the approved materials.

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Complete form and send to:

mta@gtrc.gatech.edu

Questions? Please call (404) 894-6940

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