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.	□Nikon A1RMP2 Two-photon microscope
□Nikon Ultra-wide Two-photon microscope
□Nikon A1R Confocal microscope
□Leica TCS SP8 STED 3x Super resolution STED microscope
□Light sheet microscope RAPID
□OLYMPUS MVX-10 Macro zoom microscope
□KEYENCE BZ-700 All in one microscope
□Ultrasound Imaging system
□Virtual reality system	
	□Patch Clamp system (Patch clamp amplifier + Manipulator)	
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.	
Submission of a written pledge	When using the equipment and fixtures of the Imaging Core, the laboratory concerned will be responsible for repair and reimbursement in case of damage in accordance with the Terms of Use. Such cost regarding the ultrasound imaging system and ultra-wide two-photon microscope is likely to be particularly high, so if you have checked the box for the microscope you wish to use, you will need to submit a separate pledge form in advance.
□Yes	

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