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Investigator-Initiated Research Study Application

"*" indicates required fields

Name of Institution*

Date of Application*

Contact name

Phone*

Email*

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

NPI Number and State Licence Number(s) (US Investigator Only)

Study Title*

Therapeutic Area (TA):

Acromegaly

NETs

Carcinoid Syndrome

CHI

Cushing's Syndrome

CAH

Hypercalcemia

Other

Study Hypothesis*

Primary and Secondary Objectives*

Support Requested. Please include the type of support, product and/or financial support, including amount/quantities for products.*

Estimated total study budget. Please attached a detailed line-item budget.*

State estimated timeline for study completion. Please include all phases (initiation, recruitment/enrollment, etc.).*

Additional information relevant to this proposal:

Key points for Consideration

If your request for support is approved, you will be required to enter into a written grant agreement with Crinetics. Crinetics has drafted the terms of its agreement to be balanced, reasonable and to further the goals of both parties. Negotiating grant agreements requires significant resources, so please ensure that your institution is able and willing to abide by standard agreement terms before proceeding with submission of your application as they will need to be accepted to proceed.

Letter of request*

Max. file size: 50 MB.

Signed and dated on your organization’s letterhead

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Medical Education Grant Application

Key Points for Consideration

Investigator-Initiated Research Study Application

Key points for Consideration