To encourage storage of unusual cell cultures in the Repository, 

 provision has been made for delayed release to other investigators if the 

 contributor so desires. Please check your preference: a) release culture 



to anyone requesting it , b) release only to contributor during the 



first year . At the conclusion of 1 year the cell culture will 



be listed in the next printing of the catalog and made available to other 



investigators unless additional time is specifically requested. 



I hereby grant permission for these cells to be stored in a bank 

 of genetic mutant cell cultures and the progeny cells distributed to 

 qualified investigators. Appropriate consent was obtained from the 

 patient from whom the cells were originally obtained, or can be reason- 

 ably inferred, for use of these cells for diagnosis, research, teaching 

 or therapy. 



No biopsies or cell cultures submitted to the Human Mutant Cell 

 Repository are to be obtained from a live fetus, defined by the presence 

 of pulse, circulation and other vital signs. 



Date Submitter 



( Signature) 

 Address 



Telephone Number 



Mail completed form with, or preferably preceeding shipment of cell 

 cultures, to: Dr. Arthur Greene, Institute for Medical Research, 

 Copewood and Davis Streets, Camden, New Jersey 08103. 

 Phone: 609-966-7377. 



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