Frederick Seitz Materials Research Laboratory
Central Facilities

Facility Use Proposal Form for Industrial Use

Title of Research Proposal:
Company Name:

A signed TTA or FUA must be on file before work can be started. Once your proposal submission is complete, the appropriate forms will be mailed to the Primary User for signatures.
Statement of Work:
(i.e. what work will the FSMRL perform)
Work to be performed by:  Company employee  FSMRL facility staff
Will a Non-Disclosure Agreement be required?  Yes  No
May the University publish test results to third parties orally and in writing after a prescribed review period by the Company?  Yes  No
Value of Testing Agreement: $
If the U.S. government is the source of any of the funds paid by COMPANY under this agreement, then COMPANY represents the following Are Federal Funds being used for this project? Yes No
Percent of federal funds:% CFDA #:
Federal agency providing funds:
Are the funds subject to audit? Yes  No
Audit standards: OMB Circular A-133 or Other (You will be asked to attach pertinent information.)
(Address to which all notices pertaining to the agreement should be sent.)

(Street address required for courier delivery. An email address can be added for electronic communication.)

Proposal Information:

Proposal is: New     Change of Scope
If Change of Scope, please list current User Number :
Subject of Proposal
(Check all that apply)
 Materials Science Physics Chemistry
Polymers Medical Applications Biological & Life Sciences
Earth Sciences Environmental Sciences Optics
Engineering Instrument / Technique
1. About Your Investigators
Primary User:
First Name:
Last Name:
Work Address:
Work Phone:
Alternate / Home Phone: (optional)
FSMRL contacts or collaborators:
Check all that apply, at least one.

If unknown, check Mauro Sardela (Director of Facilities)
Mauro Sardela Steve Burdin CQ Chen Jeff Grau
Doug Jeffers Rick Haasch Jim Mabon Lou Ann Miller
Remy Tao Shang Julio Soares Jessica
Timothy Spila Wacek Swiech Kathy Walsh Xiaoli Wang
Zhiyu 'Jade' Wang Lon Westfall Honghui Zhou