OPTICAL MICROSCOPY CORE

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OPTICAL MICROSCOPY CORE
Account and User Authorization Form
Medical Research Building, Room 10.120 (Mail Rt. 1043)
Phone: 409-772-3970
Contacts: Adriana Paulucci and Leoncio Vergara
E-mails: [email protected]; [email protected]
State the purpose of this form
New account_____
Change account_____
Add user_____
Delete user_____
Principle Investigator:______________________________________________________
Department:___________________ Building and Room:__________________________
PI’s Phone number:____________________ E-Mail: ____________________________
Account Information
Dept. Accounting contact:_________________________________ EXT:____________
FRS number: ___________________________ Departmental ID number:____________
Grant’s Ending Date: _______________________
INDIVIDUAL(S) AUTHORIZED TO USE OMC SERVICES WITH THIS ACCOUNT
Add Delete Print full Name
e-mail
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____________________________________
_____________________
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____________________________________
_____________________
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____________________________________
_____________________
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____________________________________
_____________________
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____________________________________
_____________________
PI: To avoid billing errors, a new form must be completed and signed every time there is a change in
the account or user list, PARTICULARLY if a user is no longer with the laboratory. Please indicate
in front of the user name DELETE or ADD.
________________________________
Primary Investigator’s Signature
_____________
Date
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