Transfer Request Collection Information Name of principal investigator (PI): * Faculty: * - Select -Faculty of ScienceFaculty of EngineeringFaculty of MedicineFaculty of ServicesOther Department: * Building name: * Room number (If this is an open concept lab, please include work station identifier): * Contact person: * Contact title: * Contact phone number: * Contact person email: * Principal investigator email: Collection day: * - Select -MondayTuesdayWednesdayThursdayFriday Collection time: * - Select -9 a.m. - noon1 p.m. - 4 p.m.Other: Drop-off Information Name of principal investigator (PI): * Faculty: * - Select -Faculty of ScienceFaculty of EngineeringFaculty of MedicineFaculty of ServicesOther Building name: * Room number: * Contact person: * Contact title: * Are you authorized to request this purchase from the Science Store? * - Select -NoYesN/A Contact phone number: * Contact person email: * Principal investigator email: Drop-off day: * - Select -MondayTuesdayWednesdayThursdayFriday Drop-off time: * - Select -9 a.m. - noon1 p.m. - 4 p.m.Other: We will do our best to accommodate your busy schedule, however, there is no guarantee on the chosen date and time Hazardous Materials Details 1 Description and identification: * Container type/size: * # of units: * Insurable value – please enter replacement costs, if there is no cost enter 0: * Is this request for a new bottle or refill of existing approved bottle? * - Select -NewRefill Hazardous Materials Details 2 Description and identification: Container type/size: # of units: Insurable value – please enter replacement costs, if there is no cost enter 0: Is this request for a new bottle or refill of existing approved bottle? - None -NewRefill Hazardous Materials Details 3: Description and identification: Container type/size: # of units: Insurable value – please enter replacement costs, if there is no cost enter 0: Is this request for a new bottle or refill of existing approved bottle? - None -NewRefill Hazardous Materials Details 4: Description and identification: Container type/size: # of units: Insurable value – please enter replacement costs, if there is no cost enter 0: Is this request for a new bottle or refill of existing approved bottle? - None -NewRefill Hazardous Materials Details 5 Description and identification: Container type/size: # of units: Insurable value – please enter replacement costs, if there is no cost enter 0: Is this request for a new bottle or refill of existing approved bottle? - None -NewRefill Hazardous Materials Details 6: Description and identification: Container type/size: # of units: Insurable value – please enter replacement costs, if there is no cost enter 0: Is this request for a new bottle or refill of existing approved bottle? - None -NewRefill Additional Information: Additional Information: Receiver signature: Consigner signature: Collector signature: Disclaimer Notice of Collection of Personal Information In accordance with the Freedom of Information and Protection of Privacy Act of Ontario and with University Policy 90, your personal information is collected under the authority of the University of Ottawa Act, 1965. The personal information you provide on this form will be used by the University for purposes consistent with administrating and carrying out University programs, services and activities relating to the planning, review or delivery of programs or services and compliance with policies, procedures and regulations. The information provided in this form will be shared with a third party organization. If you have questions about the collection, use and disclosure of your personal information in this notice, please contact Office of Risk Management at 613-562-5892 or via email at enviro@uottawa.ca Thank you!
