MATERIAL TRANSFER AGREEMENT REQUEST
Before filling out this form, please read the Material Transfer Agreement Guidance for Investigators. Material
Transfer Agreements (MTAs) protect the University’s intellectual property rights in materials you’ve created and
indicate what the recipient can and can’t do with them. They should routinely be used whenever you’re sending out
something unique that you have created (e.g. genes, proteins, hybridomas, crystallographic data, compounds,
semiconductors, software etc.), whether to a company or another academic researcher. The information on this
form will allow us to quickly get a signed MTA in place. When it is, we will notify you that the material(s) requested
may now be sent. Please fax or email a signed pdf copy of the completed form to Janine Anderson at the Office of
Technology Transfer at 353-6141 or jandersn@bu.edu, respectively. Call 353-4550 with any questions.
BU Provider
Name:
________________________________________
Email: ____________________
Phone:
________________________________________
Fax:
Lab location (Building & floor):
____________________
_____________________________________________________
Campus:
CRC
BUMC
Lab Chief Signature: ___________________________________
Date: _____________________
Requestor
Name:
________________________________________
Phone:
______________
Institution:
________________________________________
Fax:
______________
Address:
________________________________________
Email:
______________
________________________________________
________________________________________
Materials
Requested
_______________________________________________________________
_______________________________________________________________
Intended
Use
_______________________________________________________________
Tetracycline-Inducible Element:
Does the material contain the Tet-On System or Tet-Off System?
Yes
No
For Transfer of Mice:
Strain Name:_________________________________
Name and function of gene: ______________________________________
Intended use:
For experimental use only (no breeding)
For breeding and experimental use in a research institution
For breeding and commercial use (e.g. resale of animals, or sale of their offspring or
products derived from this strain)
Other (describe) : ____________________________________________
To recover costs, industrial users are usually charged a standard fee of $2,000. Should we request this fee in this
case?
Yes___ How Much? ______ No___
Export of Materials Checklist
Export control laws are federal regulations that define the conditions under which certain information, technologies,
and commodities can be transmitted to individuals overseas (including U.S. citizens). If you are shipping materials
overseas, the materials may be subject to federal regulation. Please determine if the following criteria are met:
Item will not be shipped to or through the Balkans, Burma, Côte d’Ivoire, Cuba, Iran, Iraq, Liberia, Libya,
North Korea, Sudan, Syria or Zimbabwe and services will not be provided in any of these countries
Item is not designed or adapted for a military application and does not relate to and will not be used in
connection with weapons of mass destruction or terrorism
The intended recipient is not on any the following lists:
- The Denied Persons List: http://www.bis.doc.gov/dpl/Default.shtm
- The Unverified List: http://www.bis.doc.gov/Enforcement/UnverifiedList/unverified_parties.html
- The Specially Designated Nationals List: http://www.treas.gov/offices/enforcement/ofac/sdn/
- The Entity List: http://www.bis.doc.gov/Entities/Default.htm
- The Debarred List: http://pmdtc.org/debar059.htm
No “red flags” from the Department of Commerce “Red Flag” list are present.
http://www.bis.doc.gov/Enforcement/redflags.htm
The material to be transferred does not appear on the Commerce Control List
(http://www.access.gpo.gov/bis/ear/ear_data.html) or the U.S. Munitions List
(http://fas.org/spp/starwars/offdocs/itar/p121.htm). Summaries of the categories of materials covered by
these lists are below. You should review the entire list(s) online if the material you plan to transfer fits
within one of the categories.
If you are unable to confirm any of these statements or have any questions contact Christy Talley in the Office of the
General Counsel at 617-353-2326 or ctalley@bu.edu.
I certify that I have undertaken any investigation necessary to answer these questions and have answered these
questions truthfully to the best of my knowledge.
_____________________________________
Signature
_____________________
Date
Name (printed): ________________________________________________________
Commerce Control List
http://www.access.gpo.gov/bis/ear/ear_data.html
Category 0 - Nuclear Materials, Facilities & Equipment (and Miscellaneous Items)
Category 1 - Materials, Chemicals, Microorganisms, and Toxins
Category 2 - Materials Processing
Category 3 - Electronics
Category 4 - Computers
Category 5 (Part 1) - Telecommunications
Category 5 (Part 2) - Information Security
Category 6 - Sensors and Lasers
Category 7 - Navigation and Avionics
Category 8 - Marine
Category 9 - Propulsion Systems, Space Vehicles and Related Equipment
Munitions List
http://fas.org/spp/starwars/offdocs/itar/p121.htm
Category I Firearms
Category II Artillery Projectors
Category III Ammunition
Category IV Launch Vehicles, Guided Missiles, Ballistic Missiles, Rockets, Torpedoes,
Bombs and Mines
Category V Explosives, Propellants, Incendiary Agents, and Their Constituents
Category VI Vessels of War and Special Naval Equipment
Category VII Tanks and Military Vehicles
Category VIII Aircraft, [Spacecraft] and Associated Equipment
Category IX Military Training Equipment
Category X Protective Personnel Equipment
Category XI Military [and Space] Electronics
Category XII Fire Control, Range Finder, Optical and Guidance and Control Equipment
Category XIII Auxiliary Military Equipment
Category XIV Toxicological Agents and Equipment and Radiological Equipment
Category XV Spacecraft Systems and Associated Equipment
Category XVI Nuclear Weapons Design and Test Equipment
Category XVII Classified Articles, Technical Data and Defense Services Not Otherwise
Enumerated
Category XVIII [Reserved]
Category XIX [Reserved]
Category XX Submersible Vessels, Oceanographic and Associated Equipment
Category XXI Miscellaneous Articles