Expression of Interest (Indivduals/Business)

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EXPRESSION OF INTEREST (EOI)

Please complete this form and upload a detailed CV and academic record of the applying Principal Investigator (if applying as individual/Investigator Initiated study). Your information will be sent to adnet-info@unimelb.edu.au

Date of this EOI(Required)

Applicant type(Required)

Individual/investigator initiated study

Biotech/start-up

Pharmaceutical company

Legal Name of the Entity Applying (Applicant)(Required)

Applicant’s Business Address(Required)

Applicant’s ABN (for Australian organisations)

Applicant’s principal business(Required)

Short Description

Principal Contact(Required)

Name of the Principal Contact for this application

Email(Required)

Email for all correspondence regarding this application

Phone(Required)

Best contact number

Principal Investigator(Required)

Name of Principal Investigator

Additional contact details

Other relevant contact information

Proposed technological enhancement, innovation or R&D program using ADNeT data and/or samples(Required)

1-2 paragraphs maximum

Project outline: Describe how the proposal would add value current knowledge of Alzheimer’s or other neurological disease.(Required)

1-2 paragraphs maximum

Please include comment on: Potential to collaborate amongst ADNeT parties(Required)

1-2 paragraphs maximum

Information/data required from ADNeT(Required)

Data

Biological samples

Participants from trial ready cohort

Please provide details of data/material/participants requested(Required)

Note: Samples are strictly limited and only in rare circumstances will requests over 200 µl be accepted.

How will the information be used and/or published?(Required)

Terms and Conditions

By signing this EOI, the Applicant acknowledges the following Terms and Conditions:

In order to further ADNeT, ADNeT parties reserve the right to seek financial returns or in some circumstances equity in an Applicant’s program that uses ADNeT results and materials. The nature of the consideration will be decided on a case by case basis depending on the circumstances of each EOI. The terms of any access to ADNeT study results and materials will be negotiated only after the ADNeT Management Committee has reviewed and approved the Applicant’s EOI. This EOI is not intended to be legally binding, and where the Applicant is not an ADNeT party, is subject to execution of a contract formalizing those terms (EOI Agreement or Project Agreement), which will include agreement by the Applicant to observe the Publications Guidelines pertaining to ADNeT.

Signed by the Applicant

Signature of director/duly authorised representative(Required)

Name (print)(Required)

Type out full name

Date Signed(Required)

Max. file size: 10 MB.

Please attach a detailed CV (PDF recommended)

Academic Record

Max. file size: 10 MB.

Please attach your Academic Records

Approvals (office use only)

Approved by Management Committee?

YES / NO

Approved by Management Committee to enter into project involving data/samples involving other longitudinal cohorts?

YES / NO

Notes
If the Applicant is not an ADNeT party or is collaborating with a party who is not an ADNeT party, this approval is contingent on final legal contracts being entered. If during the course of generating such contracts it is determined that the transaction needs to go through ADNeT’s commercial approval process and/or oversight committees, other approvals will be required.

Professor Christopher Rowe
Director – ADNeT

Date

Expression of Interest (Indivduals/Business)

EXPRESSION OF INTEREST (EOI)

If the applicant is a company, also complete the below:

Terms and Conditions

Approvals (office use only)