CHW Tumour Bank Application Form

Name:

Institution:

Address:

Delivery Address (if different from above):

Email Address:

Telephone:

Fax:

Title of project:

Anticipated year of commencement:

Anticipated year of completion:

Project Description: (include a brief literature review, justification of project, methods that will be used, sample number calculations if applicable, and a list of related publications)

Description of samples required from CHW Tumour Bank:

Number of samples required:

Place a tick next to the most appropriate regarding project funding status Pending approval of grant application Grant application approved (include copy of approval letter) Institutional funds available (provide statement from Institutional Head)

**A copy of Ethics Committee approval letter for proposed work on samples must be included.**