RESEARCH DEVELOPMENT AND ADMINISTRATION Sponsored Projects Administration Mail code: AD220 • 2525 S.W. First Avenue, Suite 220 • Portland, Oregon 97201-4753 503 494-0355 • Fax 503 494-1191 www.ohsu.edu/research/rda/spa
Invoice Number: Invoice Date: Due Date:
Upon Receipt
BILL TO:
Name: Attn: Address: Address: City/State/Zip
Remit payment to: Oregon Health & Science University Attn: Cash Management / Sponsored Projects Admin. 2525 SW 1st Avenue, Suite 220 Portland, OR 97201-4753 Tax ID#: 93-1176109
SERVICES FOR:
Study Title: PI: IRB #: Protocol / Study #: Sponsor’s PO#: Award / Project #: Description Unit Price Total
Quantity
Total Previous Unpaid Invoices Invoice Number
$ $ $ $ $ $ $ $ $ $ $ $ $ $
-
Date
Amount
Total Previous Unpaid Invoices
Approved:
$
-
Type PI's Name:
PI's Signature:
Re
Date:
Please reference the PI's name and the Study Number on the check and return a copy of this invoice with the payment.
If you have any questions regarding this invoice, please contact:
503-494-XXXX
Name: Phone: Email: Revised 4/17/07
Department / Division Address
Invoice Number: Invoice Date: Due Date:
DEPT - 2004-06 May 21, 2004 Upon Receipt
BILL TO:
Name: Attn: Address: Address: City/State/Zip
A Good Sponsor Attn: M.Y. Rep 41 Research Ave. Building #1, Suite 100 Industry City, MA 02453
Remit payment to: Oregon Health & Science University Attn: Cash Management / Sponsored Projects Admin. 2525 SW 1st Avenue, Suite 220 Portland, OR 97201-4753 Tax ID#: 93-1176109
SERVICES FOR:
Study Title: A Phase II, Randomized, Double-Blind, Placebo-Controlled, MultiCenter, Parallel-Group, Study to Assess the Efficacy, Safety and Tolerability of a Drug or Device in Human Subjects PI: IRB #: Protocol / Study #: Sponsor’s PO#: Award / Project #:
Dr. A. Grant Investigator 9999 AGS-4431 4900045 AOHSU9999 / GOHSU9999A
Unit Price Total
Quantity
Description
2 1
Contract fee for completed Subjects Contract fee for partial completion (2 visits)
$ $
5,300.00 1,007.00
Total Previous Unpaid Invoices Invoice Number
$ $ $ $ $ $ $ $ $ $ $ $ $ $
10,600.00 1,007.00 11,607.00
Date
Amount
March 15, 2004 February 4, 2004
DEPT - 2004-05 DEPT - 2004-04
$ $
21,200.00 10,600.00
Total Previous Unpaid Invoices
Approved:
$
31,800.00
Dr. A. Grant Investigator
Type PI's Name: PI's Signature: Re Date:
Please reference the PI's name and the Study Number on the check and return a copy of this invoice with the payment.
If you have any questions regarding this invoice, please contact:
Joan Invoicecreator
Name:
503-494-XXXX
Phone: Email: Revised 4/17/07