Duke University Viral Vector Core Order Form Please send completed from via FAX 919.613.6750, or email: viral.core@duke.edu Investigator Information Investigator: Contact (if other than PI): Institution: Phone: FAX: Email: Shipping Address: Accounting Information Accounting Contact: Phone: FAX: Account Address: Duke Account# OR Purchase Order# Project Information Project Description: Gene of Interest: (G of I) accession# (G of I) Promoter Please check if vector will be used in animals If yes, please list species

Services Requested Agreement Lentiviral Vector: Generation, purification & concentration Please check if 10mL requested (non-concentrated) 107 vg/mL Please check if 25uL requested (concentrated-for in-vivo, neuron-grade) 109 vg/mL Please check if 100mL requested (non-concentrated) 107 vg/mL Please check if 150uL requested (concentrated-for in-vivo, neuron-grade) 109 vg/mL Please check if 100uL requested (concentrated-not for neurons) 109 vg/mL Please check if 500uL requested (concentrated-for in-vivo, neuron-grade) 109 vg/mL Adeno-Associated Vector: Generation, purification & concentration Please check if 100uL requested (not-suitable for neuron transduction) 1011 vg/mL Please check if 1mL requested (not-suitable for neuron transduction) 1011 vg/mL Please check if 50uL requested (in-vivo; suitable for neuron transduction) 1012 vg/mL Please specify serotype Please check if 1mL requested (in-vivo; suitable for neuron transduction) 1012 vg/mL Agreement Safety information of the gene of interest has been provided above to the best knowledge of the Primary Investigator (PI). The PI has or will register the vector described above with the Institutional Biosafety Committee or its equivalent at his/her institute. Published study involving use of any gene transfer vectors prepared at the Duke University Viral Vector Core must acknowledge the Vector Core. The PI will provide the Vector Core with a publication record. Gene transfer vectors prepared by the Vector Core are not for application in human beings. Both Duke University, and the Vector Core shall not be held liable for any outcome in connection with use of the vectors by the PI. PI signature: Date: