NOTE:  Required fields are indicated by a red asterisk *

 



 

 

 

MASSACHUSETTS INSTITUTE OF TECHNOLOGY

Materials Science and Engineering Center

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 *

Telephone 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.)

 

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 MRL 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 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 MRL 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 MRL, 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 MRL 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 MRL before any use of the facilities will be permitted.

 

 

 

FOR THE MATERIALS RESEARCH LABORATORY

 

Action:                               Effective Date:                              Expiration Date:                    

            Approve/Deny

 

 

Rate Schedule Authorized:  Standard

 

 

Comments:

 

 

 

 

 

                                                                                      

Susan Dalton                                        Date           

Assistant Director                                                             

 

 

                                                                                                              SEF Non-Academic Application Form online version 9/2008