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.
-----------------------
Complete form and send to:
mta@gtrc.gatech.edu
Questions? Please call (404) 894-6940
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