Plastination Request Form for Printing

REQUEST FOR PLASTINATION SERVICES FROM THE UNIVERSITY OF MICHIGAN
Instructions: Fill out items 1-8 below and return to:

Dr. Ameed Raoof
Plastination Laboratory
Office of Medical Education
The University of Michigan Medical School
3606 Medical Science II Bldg.
Ann Arbor, MI 48109-0608
FAX: (734) 615-8191

Name:

Date:

Institution:

Department:

Address:

City: State:

Zip:

Phone: FAX:

Email:

Federal Express Account #: Recharge Account #:

1. Title of Project or Course:

2. Contact Person: Phone:

3. Description and number of specimens requested:

4. Institution providing material to be plastinated:

5. Will material be used outside the facilities of the Department of Anatomy & Cell Biology? __________ If so, specify location of use:

6. Describe specimen use and storage arrangements:

7. If my request is approved, I understand that I will be charged a fee for the preparation and use of my plastinated specimens. I will receive them on loan from The University of Michigan, will assume all responsibility for them and will use them only in the manner herein described. I agree that if any specimen is either lost or stolen, I will be financially liable for its full replacement price as detailed in the Plastination Price Schedule.

8. Signature of Course/Project Director:

_____________________________________________________________________________

U of M use only
Approved? Yes________ No_________ Signature _______________________________

Return to Plastination Laboratory

Name:		Date:
Institution:
Department:
Address:
City:	State:	Zip:
Phone:	FAX:	Email:
Federal Express Account #:	Recharge Account #:
1. Title of Project or Course:
2. Contact Person:		Phone:
3. Description and number of specimens requested:
4. Institution providing material to be plastinated:
5. Will material be used outside the facilities of the Department of Anatomy & Cell Biology? __________ If so, specify location of use:
6. Describe specimen use and storage arrangements:
7. If my request is approved, I understand that I will be charged a fee for the preparation and use of my plastinated specimens. I will receive them on loan from The University of Michigan, will assume all responsibility for them and will use them only in the manner herein described. I agree that if any specimen is either lost or stolen, I will be financially liable for its full replacement price as detailed in the Plastination Price Schedule.
8. Signature of Course/Project Director: _____________________________________________________________________________