Transfer request

Collection information

Name of principal investigator (PI):

Principal investigator email:

Faculty:

Department:

Room number (If this is an open concept lab, please include work station identifier):

Contact person:

Contact title:

Contact phone number:

Contact person email:

Collection day:

Collection time:

Enter time:

Drop-off information

Name of principal investigator (PI):

Principal investigator email:

Faculty:

Building name:

Room number:

Contact person:

Contact title:

Are you authorized to request this purchase from the Science Store?

Contact phone number:

Contact person email:

Drop-off day:

Drop-off time:

We will do our best to accommodate your busy schedule, however, there is no guarantee on the chosen date and time

Enter time:

Hazardous materials details

Hazardous material details
Description and identification: Container type/size: Number of units: Insurable value – please enter replacement costs, if there is no cost enter 0: Is this request for a new bottle or refill of existing approved bottle? New Refill

Additional information

Additional information:

Receiver signature

Consigner signature:

Collector signature:

Sign below

Disclaimer

Notice of Collection of Personal Information

In accordance with the Freedom of Information and Protection of Privacy Act of Ontario and with University Policy 90, your personal information is collected under the authority of the University of Ottawa Act, 1965. The personal information you provide on this form will be used by the University for purposes consistent with administrating and carrying out University programs, services and activities relating to the planning, review or delivery of programs or services and compliance with policies, procedures and regulations. The information provided in this form will be shared with a third party organization. If you have questions about the collection, use and disclosure of your personal information in this notice, please contact Office of the Chief Risk Officer at 613-562-5892 or via email at [email protected].

Thank you!