h

AGRE RESEARCHER ACCESS APPLICATION

To apply for access to AGRE data and biomaterials, please fill in the following form. If you have any questions regarding your application you may contact the Clinical Research Specialist, Eve Landa, at 323-297-4750 or eve.landa@agre.org. Thank you for your interest in AGRE.

First Name *

Last Name *

Title

Email *

Institution

Phone

Fax

Address Line 1

Address Line 2

City

State

Country

Zip Code

Title of
Research Project

Name of Principal Investigator

Intended Use of Database and/or Cell Lines/DNA/serum

Funding Source

Research Associates and Titles

Project Abstract

Brief Abstract for Website Display

IRB Approval/Exemption Date

Copyright © 2011 AutismSpeaks, all rights reserved.