MASSACHUSETTS INSTITUTE OF TECHNOLOGY

Center for Materials Science and Engineering

Application and Agreement for

Outside Academic Organization Use of Shared Facilities

 

Section I-ORGANIZATIONAL DATA

 

ORGANIZATIONAL INFORMATION

please complete all starred  * sections below

 

APPLICATION DATE *

 

 

 

ORGANIZATION NAME *

 

ADDRESS/TELEPHONE

 

 

Department/Division

 

Room/Suite Number

 

Street Address/P.O. Box *

 

 

City */State/Zip Code

//

 

Organization Contact Person *

 

Telephone Number *

 

E-Mail Address *

 

Fax Number

 

EMERGENCY INFO

 

 

Contact Person *

 

Telephone Number *

 

 

 

 

Tax Exemption Number *

 

 

 

 

BILLING INFORMATION (Where the bill should be sent)

 

Billing Contact Person *

 

Dept. / Division

 

Room/Suite Number

 

Street Address/P.O. Box

 

City/State/Zip Code

//

 

Telephone Number

 

Fax Number

 

 

Section II-PROJECT INFORMATION

 

TITLE OF PROJECT: *

 

 

 

PROFESSIONAL PERSONNEL INVOLVED IN THE PROJECT

(List Principal Investigator on project first and include anyone within your organization or group who will use our facilities.)

PRINCIPAL INVESTIGATOR *

NAME TITLE     DEPT. TELEPHONE NUMBER

OTHER PERSONNEL

 

RESEARCH OBJECTIVES *

(Please indicate your current research goals and specify in detail the specific objectives of your research project.)

 

FACILITY/SERVICES NEEDED *  (Application will be effective for one year - reapplication required for work beyond this time frame)

  
 FACILITY/SERVICE NEEDED HOURS REQUIRED

 

 

FEASIBILITY OF PROPOSED WORK *  (Have you contacted any CMSE Staff Member concerning the feasibility of your experiment or the availability of the desired instrumentation or service?  If so, please describe.  If not, please contact the CMSE Assistant Director at (617) 253-7632 to discuss this prior to the submission of this form.)

 

 

Section III-AGREEMENT

(to be reviewed and signed)

[Please note that CMSE will not approve an application with any changes to the wording of the following paragraphs]

 

 

 

Patent Rights

The primary purpose of the Center is to provide facilities for performing basic science and engineering research.  Recognizing, however, that inventions may be made under this program, the parties agree that any invention made solely by the applicant while using Center facilities shall be the property of the applicant provided, however, that in the event such invention constitutes an improvement to or new use of equipment located in Center facilities, the applicant shall grant to MIT a royalty-free, non-exclusive license to use such inventions for purposes of education and research.  Inventions that are made jointly by employees of MIT and employees of applicant shall be jointly owned.

 

Indemnification

The applicant shall indemnify and hold harmless, MIT, its trustees, officers, employees and students, from any and all loss, cost, damage, and expense of whatever nature or kind which may arise from the applicants use of the Center including, but not limited to, property damage and personal injury or death, unless caused by the proven negligence of MIT.  The applicant shall have in effect at all times sufficient insurance to cover any claims that may be brought against MIT arising out of the applicants use of Center facilities.

 

Agreement

Typing your name and the date in the boxes below acts as your signature to certify that you are authorized to execute this application, and you agree to the above terms and conditions and to follow the guidelines for outside use of Center Facilities.

 

FOR THE APPLICANT ORGANIZATION *
PRINCIPAL INVESTIGATOR DATE   -OR- AUTHORIZED ADMIN. OFFICER  DATE
 

Please note:  After this application is approved, a purchase order covering the anticipated cost of the work must be received by CMSE before any use of the facilities will be permitted.

 

 

 

FOR THE CENTER FOR MATERIALS SCIENCE AND ENGINEERING

 

Action:                               Effective Date:                              Expiration Date:                    

            Approve/Deny

 

 

Rate Schedule Authorized:  Academic

 

 

Comments:

 

 

 

 

 

                                                                                        

Susan Dalton                                         Date                                     

CMSE Assistant Director                                                             

 

 

                                                                                                                       SEF Academic Application Form online version 9/2008