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Confidential Request for Access to Dossier Materials

This form must be completed by any entity seeking access to restricted materials related to PLPC-DB™, including but not limited to: the

CTD dossier, STIP registry, SAP audits, PET-FDG subgroup data, and strategic documentation.

All information will be handled in strict confidence and used solely to evaluate NDA eligibility.

I. ORGANIZATIONAL INFORMATION

• Institution / Company Name:

• Jurisdiction of Incorporation

• Entity Type

• Primary Contact Name

• Position / Title:

• Phone Number

• Email Address

II. REQUESTED PURPOSE (Select all that apply):

III. DECLARATION

By submitting this form, the requester declares:
1. That they are authorized to represent the entity named above.
2. That the information provided is accurate and complete.
3. That they understand PLPC-DB™ is a structurally closed, non-public asset, and that access is granted solely under confidentiality protocols.
4. That they agree not to disseminate or disclose any portion of the information received unless expressly authorized.

Signature:

Name:

Date:

Please return this form to: Department of Oncopathology – OGRD Alliance
plpc@ogrdalliance.org
Subject: “NDA Request – [Institution Name]”
A member of our team will respond within 48 hours with documentation access instructions.

Confidential Request for Access to Dossier Materials

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