Material Transfer Agreement
Living Collections Access and Distribution Form
(Form must be returned for approval at least one week prior to proposed collection date)
User Information (To be filled out by or on behalf of primary user)
Today’s Date: ____________________________ Proposed Date of Collection: ________________
Name: ___________________________________ Telephone #: ____________________________
Position: _________________________________ Email Address: ____________________________
Organization: ___________________________________________________________________________
Mailing or shipping address: _____________________________________________________________
_____________________________________________________________
___________________________ _________________ _______________
FedEx Account # (if applicable) ____________________________
Collection use:
Project Description (please attach an addendum if needed)
Please note any additional requirements/requests for collection or shipping:
Use/Project Type (check one or more box)
☐ Breeding/Hybridization
☐ Conservation Research
☐ Horticultural Display
☐ Horticultural Research
☐ Molecular Research
☐ Propagation
☐ Research (other) ______________________
☐ Teaching
☐ Other _______________________________
Is there an intent to commercialize? ☐ No ☐ Yes (if yes, this will serve as a conditional agreement, with a new
agreement drawn up for commercial use)
Plant Records Staff Use Only
Source Number: Shipment Number(s):
Date entered: Staff Contact:
