Clinical Research Print Request

This form is for use with IRB-approved study materials only.

Please Do Not Type In All CAPS

_________________________________________________________________________________

IRB Protocol Number:

Name of Primary Investigator/Study Director: Study Title:

Please e-mail any materials to Clinical Research Advertising with your IRB# and the words "print request" in the subject line.

Please check the boxes next to the type of advertising you would like to use for this study:

Please provide the following contact information:

Last Name:
First Name:
Department:
Mail Code:
Phone:
Fax:
Your E-Mail Address:
Delivery Address:
Pick-up at ASB 1200 (please allow three business days for processing
Delivery via interoffice mail
Do you need additional plastic holder pockets (for take-away tabs you create yourself): Yes No

Please only select the "Submit Form" button once. You will receive a confirmation page.

Questions may be directed to Clinical Research Advertising.

For suggestions or comments about the Penn State Marketing and Communications website, please email Ann Guerrisi-Hawn.

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