Waiver of Indemnification
Agreement
This form must be completed by individuals at
institutions that cannot sign either the Standard Indemnification Agreement or
the State Institution Compliance Agreement The Recipient Institution,
__________________________________________________
______________________________________________________________________________
is unable to comply with the Standard Indemnification
Agreement or, if it is a state institution, with the terms of the State
Institution Compliance Agreement. As a result, the recipient acknowledges that
the NHLBI Biologic Specimen Repository will not provide specimens that are
known to be biologically infectious.
| __________________________________ |
_____________________________ |
| *Officer of Institution or Company
(Signature) |
Requestor (Signature) |
______________________________ |
______________________________ |
| Printed Name |
Printed Name |
______________________________ |
______________________________ |
| Title |
Title |
______________________________ |
______________________________ |
| Institution |
Institution |
______________________________ |
______________________________ |
| Date |
Date |
*This officer cosigning above must be capable of
legally binding the institution
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Department of Health
and Human Services
National
Institutes of Health
National Heart, Lung, and Blood
Institute