User Form
All fields are required except indicated separately. Missing information may delay the processing of your application. |
Submit Type |
Submit Type : | |
User Information |
User From : | |
MCB 481 Course : | |
First Name : | |
Last Name : | |
UC ID : | |
User Status : | |
E-mail : | |
Work Phone : | |
Other Phone : | |
Department : | |
Insititution / Company : | |
Work Address : | |
Supervisor Information |
PI First Name : | |
PI Last Name : | |
PI Phone : | |
PI Email : | |
Billing Information |
Please provide the billing account number. UC users should provide a complete chartstring. (UCB format Acct-Fund-Org-Pgm-Sub type (e.g. 12345-67890-44--ABCDE); other UC formats may vary, use CCOA if possible). For LBNL users, please provide the IUT Number. |
Please provide the federal tax ID
and a purchase order (PO) number. We only accept checks for payments. |
Federal Tax ID : | |
Billing Account / PO : | |
Billing Address : | |
Billing Contact Person : | |
Billing Phone : | |
Billing Email : | |
Reason for Use EML |
This description should indicate the
nature, scope, and expected results of your research project.
|
EM facility to use : | |
Reason for Use : | |
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