NIMH Chemical Synthesis and Drug Supply Program

NIMH Order Form

Instructions: Please fill out the following form completely, and press the "order now" button when you are finished. If you are requesting a radiolabeled compound, please fax a copy of your current NRC license to Ken Rehder at RTI International 919-541-8868.

1. Compound Requested:
MH No.:
Chemical Name:
Amount:

2. Brief description of intended use and importance of research to neuroscience:

3. Description of protocol to be used, including detailed justification on the requested amount.
(See Ordering Information for instructions.):

4. Literature citations dealing with target compound or related compounds.:

5. Primary source of funding for proposed research:

6. Publications resulting from inventory compounds:

7. Shipping Address for compound:	8. Mailing address (if different than 7.):

9. Telephone/Fax Numbers:

10. Name of scientist requesting compound(s):

11. Email Address: