Biomedical Engineering (BME) Atomic Force Microscopy (AFM) Equipment 
              Authorization for Charges (Non-OSU)

Company Name: __________________________________________________________

P.I. Name: _____________________________________________________________

Billing Address: _______________________________________________________

Contact Phone: ______________________   E-mail: ________________________


User Information

Name: __________________________________________________________________

Address: _______________________________________________________________

Phone/Pager: ________________________  E-mail: _________________________

Date Submitted: ________________________________________________________



Instructions

1. To avoid delays in processing your application, provide all
   information requested.  Please print legibly.

2. In order to use the AFM equipment, the Company and Principal
   Investigator must assume responsibility for usage charges.  If a
   current Authorization for Charges form is not on file with our BME
   Administrator, one will need to be completed by the
   Company/Principal Investigator before usage will be permitted.

3. Return all completed signed forms to the BME Administrator.  Access
   may be denied until all required documents have been turned in to
   the Administrator.

Send completed forms to:
Kirsten Gibbons, Administrator,
Biomedical Engineering, 270 Bevis Hall,
1080 Carmack Rd., Columbus, Ohio 43210

Phone: (614) 292-1625
Fax: (614) 292-7301
E-mail: gibbons.40@osu.edu