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Application for ICPSR Restricted Data Files

INSTRUCTIONS: Please provide the following information. Additional information may be attached to this form. Please note that only one application per research project is required. However, separate Data Protection Plans and Data Use Agreements are required for each organization represented by the research team.

1. Study Title:

Study Number:

2. Applicant information: (Note: Unless otherwise instructed, the first Principal Investigator listed will serve as the primary contact person with ICPSR.)

Name of Principal Investigator:

Title:

Department (if applicable):

Organization:

Street Address:

City, State, ZIP:

Phone:

Fax:

Email:

Name of Co-Principal Investigator (if applicable):

Title:

Department (if applicable):

Organization:

Street Address:

City, State, Zip:

Phone:

Fax:

Email:

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