QUALIFICATION FORM FOR NIH-SPONSORED APLYSIA PURCHASES
(Please complete a separate form for each NIH funded project)
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1. PI Name:

2. PI Institutional Address:


Phone #:

Email Address:

3. Names of Co-PIs:

4. Title of NIH-Sponsored Project (please complete a separate form for each project):


5. NIH Grant Number:

6. Dates of Award:

7. a. Total Direct Cost: b. Total Cost:

8. NIH Institute Contact Person Name:

Phone #:

Email Address:

9. Name and Address of Billing Contact at Your Institution:




Phone #:

Email Address:


Please Remember to Attach an Abstract!

(All above information is important! In order for us to continue to justify NCRR support, we must be able to continue to document extensive use of Aplysia by NIH-sponsored investigators.)


Please return form & abstract to:
Tom Capo
NIH-UM Aplysia Resource Facility

4600 Rickenbacker Causeway
Miami, Florida 33149