Request for Client Access / UserID


   * = required field

Full Name: *
Institution: *
Address: *
City:
State/Province: *
Zip/Postal Code: *
Country: *
Phone Number: *
E-mail Address: *


Non-Disclosure Agreement

I agree that access will be granted to the BioResearch Database system with the understanding that I am responsible for all activities undertaken using my UserID access code and other forms of authorization. *
YES     NO

I need access to cases submitted under my name:
AND/OR
I need access to cases submitter under another name(s):

If "another name(s)" is checked, please provide name(s) and contact information so that authorization may be verified.

I authorize on-line access to cases submitted under my name to the following person(s).  I understand that these individuals will need to apply for their own UserIDs.

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