If you are receiving software for research or educated purposes, please fill out this form.
* indicates required fields.
Principal Investigator *
SU Lab Contact/Admin Name & E-mail *
Provider Company Name *
Provider Contact Name & E-mail *
Name & description of software *
Where will the software be installed: Stanford University, SHC or LPCH? *
If the answer is SHC or LPCH, please provide the location and contact information of the SHC or LPCH person
What is the estimated total value of the software? *
What is the period of the software license?
After the license ends, will Stanford University, SHC or LPCH receive ownership of or rights to purchase the software? If so, please explain how the transfer will be carried out
Is the software available through an open source license?
Will the software be used with software from other companies, other than commercially purchased or licensed items? If so, what is the other software and who provided it? Were agreements signed for the other software?
Will the software be modified? If so, how will it be modified and who will be responsible?
If this project involves writing or adapting software, will you share with the Provider any pre-existing software that is neither open-sourced nor commercially available? If so, please describe the software
Will the software be used for research purposes? If so, provide an estimate of % time
Will the software be used clinically? If so, provide an estimate of % time
Will the software be used for research with human subjects? If so, provide IRB protocol # :
Industrial Affiliates Program
Federal contract(s) or grant(s)
Name the above funding source(s) for your research project
Advisory Board Member or Board of Directors
Ownership of stock or stock options
Attach the Word version of the agreement, if available. Do not have the PI sign the agreement until it has been reviewed by ICO:
Your E-mail *
After you click “Submit Form” below, you will receive an e-mail confirmation. We will contact the Principal Investigator and individual(s) identified as the Lab Contact/Admin about next steps. For questions, please contact: firstname.lastname@example.org
Please skip. Do not fill this out.