NOTE: Required fields are indicated by a red asterisk *
MASSACHUSETTS INSTITUTE OF TECHNOLOGY
Center for Materials Science and Engineering
Application and Agreement for
Commercial or Non-Academic Organization Use of Shared Facilities
Section I-ORGANIZATIONAL DATA
ORGANIZATIONAL INFORMATION
please complete all 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 *
BILLING INFORMATION (Where the bill should be sent)
Billing Contact Person *
Dept. / Division
Street Address/P.O. Box
City/State/Zip Code
Telephone 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.)
NAME TITLE DEPT. TELEPHONE NUMBER
PRINCIPAL INVESTIGATOR*
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.)
6. HAVE YOU CONTACTED COMMERCIAL LABORATORIES ABOUT THE POSSIBILITY OF PERFORMING THIS WORK? * (NSF Guidelines (Notice #122) prohibit us from competing with commercial laboratories. Prior to submitting this application, please contact commercial laboratories. If after this review you would still like to use our facilities, please specify the commercial laboratories contacted and why they could not provide the services that you need.)
7. WILL YOU ASK MEMBERS OF THE CMSE TECHNICAL STAFF TO SIGN A NON-DISCLOSURE AGREEMENT? * (A “Yes” answer will usually preclude the approval of this application. If Yes, please justify why you believe an exception should be made in this case, and attach a copy of the proposed agreement for review. If this question is answered “No”, any conditions or wording on any purchase order issued in connection with this application which appear to impose any obligation of confidentiality on MIT, its Faculty, Staff or Students, with respect to the work to be performed under this agreement shall be agreed to be null and void, and without effect, and such purchase order shall be accepted by CMSE, and the work will be performed, only on this understanding.)
8. IS THE PRIMARY PURPOSE OF THIS WORK RELATED TO A LAWSUIT, COURT ACTION, OR SIMILAR PROCEEDINGS, OR FOR ANY PURPOSE OTHER THAN SCIENTIFIC OR TECHNICAL INVESTIGATION RELATED TO BASIC RESEARCH OR PRODUCT DEVELOPMENT? IF NOT, IS THERE A KNOWN POSSIBILITY THAT THE RESULTS TO BE OBTAINED MAY BE USED IN CONNECTION WITH SUCH MATTERS? * (A “Yes” answer will preclude the approval of this application. If the primary purpose of the work is related to scientific or technical investigation related to basic research or product development, but it is known that the results might be used in connection with any actual or potential lawsuit, court action, or other similar proceedings, please describe the circumstances. An unqualified “No” answer will be taken as an explicit declaration that no such possibility is known or anticipated)
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
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: Standard
Comments:
Susan Dalton Date
CMSE Assistant Director
SEF Non-Academic Application Form online version 9/2008