利用申請許可番号	
	
IRCN Imaging Core Usage Application Form
　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　Entry field by Imaging Core

Entry Columns by Applicant	
Date of Application		
Institution		
Department・Lab Name		
Name of PI・Position	Name：
Position：　　　　　　　　　　　　　　　　　　　　　　　　
Signature　　　　　　　　　　　　　　　　　　   	
Address of Lab		
Phone Number of Lab.		
Mobile Phone Number of PI (for emergency)		
E-mail address of PI		
Please write all the Names of User of your Lab who wish to use Imaging Core equipment・SECOM Card No. of Users（Left Colum, 2nd Line, Right Colum 1st Line on the back side of the card）		
Please check all the microscopes and equipment that you wish to use.	□ニコン２光子励起顕微鏡　　　　　　　□VR
□ニコン共焦点レーザー顕微鏡　　　　　□パッチクランプ
□ライカSTED超解像顕微鏡
□ライトシート顕微鏡（Rapid）
□オリンパスMVXマクロズーム顕微鏡
□キーエンス BZX-700 蛍光顕微鏡	
Research Project Name		
Research Plan
（Please explain the reason why you need the checked microscope or equipment checked above）

		
Genetic recombination experiment	□Yes
□No	
Animal experiment	□Yes
□No	
Submission of Microbial Inspection Table of your animal breeding room	□Yes
□No	
Agree to the terms of use	□We agree.
It is not allowed to use without agreement.	

About the handling of personal information

1, Purpose of use of personal information
We will not use any personal information you enter except for the administration work of this facility.
We will not disclose or provide it to third parties without your consent. (Except in cases where the provisions of laws and regulations are stipulated)

2. Management of personal information
We will strictly keep the personal information you filled in and take necessary measures for safety management.

Entry Columns by Imaging Core Staff	
□受理
□受理不可
＊受理不可の場合は理由を記入	　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　	
利用申請許可番号		
利用申請許可年月日		

★When submitting the usage application form, please delete the “Flow of Using the IRCN Imaging Core”.