Application form for Target/focused screening

Principal investigator contact information

First name *

Infix (e.g. "van der")

Last name *

Form of address (title)

Position

Organisation *

Department *

Organisation address *

Phone number *

Email address *

Website URL

VAT number *

Mandatory for EU users, otherwise 21% Dutch VAT

Reference number (e.g. SAP number)

FedEx number (or other shipping company)

Collaborator(s) contact information

First name

Infix (e.g. "van der")

Last name

Form of address (title)

Position

Organisation

Department

Organisation address

Phone number

Email address

Website URL

Billing address

Is the billing address different from the address above? *

Yes

If the billing address is different from the address above, please enter the address below.

Address

Shipping address

Is the shipping address different from the address above? *

Yes

Address

User access

I would like to access this service based on *

Scientific excellence (on a reduced-cost basis, after review process)

Full-cost basis

Confidentiality

This application requires a Non Disclosure Agreement *

Yes

If your application requires an NDA, a user account through which you can upload your NDA will be created.

Project information

Project title *

Scientific background *

Brief description of the project *

Expected outcome of the data to be collected

Please state in one sentence the main research question and the research question the data could answer

Relevant publications (max. 5)

Additional information

Please state name here if applicable and attach file to upload

File upload

Files must be less than 32 MB.
Allowed file types: jpg png pdf.

Leave this field blank

Application form for Target/focused screening

NL-Openscreen Office