Form request

* Fields are required

Applicant data

Applicant Name*

Department / Service*

Institution *

Email*

DNI/CIF/NIE

NIF:

Phone number*

Name of the research project*

Project code

Team leader*

Do you have CEIC approval?

CEIC approval

Type of study*

With funding Without funding Request for new project Other (tell more)

Purpose and objectives of the study*

Samples to choose

Project

Pathology type

Number of cases

Type of samples

Sample shipping details (filling only if it is different from the applicant's details)

Applicant name

Full address

Department / Service

Phone number

Billing data (filling only if they are different from the applicant's data)

Project

Responsible

Institution

Full address

I have read and I accept the rules of use of the provided samples (see the regulations below)*

Regulation

Data protection: INSTITUT DE RECERCA BIOMÈDICA DE LLEIDA will process your data to manage and respond to your request for service at the Biobank, sent through our contact form and email. You can exercise your rights at protecciodedades@irblleida.cat. Learn about our privacy policy by clicking here.