APGI BioResource Request FormApplication for access to APGI BioSpecimens & dataBioResource Request Form Step 1 of 3 - Instructions33%Instructions to applicantsThis form has five sections (A-E). Section A, B and E are compulsory and must be completed in full. Sections B and C may be completed depending on your application needs. Some of the BioSpecimens and data are restricted as per terms of ethical approval. Please ensure you consult and familiarise yourself with the BioSpecimen and Data Access Policy and guidelines on the website: www.pancreaticcancer.net.au/research/the-apgi-bioresource/Accessing-APGI-Bioresource. At the end of this form indicate whether you agree to be bound by this policy and the Controlled Data Requirements. Upon completion, please email your paperwork (PDF format), including your supporting documents such as ethics approval, to email@example.com. Please include a short summary of your request in the email body text. Save and Continue LaterSection A - Applicant DetailsFor the purpose of this project.A.1. Name of Applicant*If the applicant is requesting ICGC BioSpecimens (including Tissue Microarrays), the applicant must be a Principal Investigator or Chief Scientific Officer. Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Middle Last Suffix A.2. Primary AffiliationPosition Title:Group:Primary Afiliation:Institution Website:A.3. Contact InformationInstitution:Address Street Address Address Line 2 City State / Province / Region Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Telephone:Institutional Email Address:* A.4. Principal Investigator DetailsPlease only complete if different from above. The Principal Investigator will be classed as the authorised institutional representative to ensure adherence to policies.Name: First Last Group:Primary Affiliation:Institution Website:A.5. Names of Authorised Personnel or Students (within your institution)Please include all investigators, collaborators and research staff who will have access to APGI controlled data in order to work on the project. Please include an additional page i further names are to be provided.Authorised Personnel Name: Group: Primary affiliation: Institution website: EditDelete There are no personnel. Add person Maximum number of personnel reached. Save and Continue LaterSection B - Project detailsThe project must be a cancer-related research project.B.1. Project InformationProject Title:Project Website:Planned project durationPlease provide start and end dates.Please note that your project will only remain approved for the stated duration of your project in this question.B.2. Project descriptionPlease provide a clear description of the project and its specific aims in no more than 500 words.Scientific abstractCommentsThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.