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Applying for Restricted Use Data - page 12 / 15

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Restricted Data Investigator Study Title:

Signature:

Date:

Typed Name:

Title:

Institution:

Building/Room Number:

Street Address:

City/State/ZIP:

Telephone:

Fax:

Email:

Representative of the Receiving Organization By signing this agreement, this organization agrees that access to these confidential data will be restricted to authorized persons whose names appear on this agreement and the Supplemental Agreement with Research Staff, and that this organization is legally bound by the covenants and terms of this agreement.

Signature:

Date:

Typed Name:

Title:

Institution:

Building/Room Number:

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