RESEARCH DEVELOPMENT AND ADMINISTRATION

Sponsored Projects Administration

0690 SW Bancroft Street • Mail Code: L106SPA • Portland, Oregon 97239
503 494-0355 • Fax 503 494-1191
www.ohsu.edu/research/rda/spa

Invoice Number:
Invoice Date:
Due Date: Upon Receipt

BILL TO: Remit payment to:

Name: Oregon Health & Science University
Attn: Attn: Award Revenue / Sponsored Projects Admin.
Address: 0690 SW Bancroft Street, L106SPA
Address: Portland, OR 97239
City/State/Zip Tax ID#: 93-1176109

SERVICES FOR:
Study Title: PI:
IRB #:
Protocol / Study #:
Sponsor’s PO#:
Award / Project #:

Quantity Description Unit Price Total

$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Total $ -

Previous Unpaid Invoices

Date Invoice Number Amount

Total Previous Unpaid Invoices $ -

Approved:

Type PI's Name: PI's Signature: 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 10/11/11
 Department / Division
Address

Invoice Number: DEPT - 2011-10

Invoice Date: October 11, 2011
Due Date: Upon Receipt

BILL TO: Remit payment to:

Name: A Good Sponsor Oregon Health & Science University
Attn: Attn: M.Y. Rep Attn: Award Revenue / Sponsored Projects Admin.
Address: 41 Research Ave. 0690 SW Bancroft Street, L106SPA
Address: Building #1, Suite 100 Portland, OR 97239
City/State/Zip Industry City, MA 02453 Tax ID#: 93-1176109

SERVICES FOR:
Study Title: PI: Dr. A. Great Investigator
A Phase II, Randomized, Double-Blind, Placebo-Controlled, Multi- IRB #: 9999
Center, Parallel-Group, Study to Assess the Efficacy, Safety and Protocol / Study #: AGS-4431
Tolerability of a Drug or Device in Human Subjects
Sponsor’s PO#: 4900045
Award / Project #: AOHSU9999 / GOHSU9999

Quantity Description Unit Price Total

2 Contract fee for completed Subjects $ 5,300.00 $ 10,600.00
$ -
1 Contract fee for partial completion (2 visits) $ 1,007.00 $ 1,007.00
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
$ -
Total $ 11,607.00

Previous Unpaid Invoices

Date Invoice Number Amount
July 15, 2011 DEPT - 2011-07 $ 21,200.00
June 4, 2011 DEPT - 2011-06 $ 10,600.00

Total Previous Unpaid Invoices $ 31,800.00

Approved:

Dr. A. Great Investigator

Type PI's Name: PI's Signature: 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 503-494-XXXX

Name: Phone: Email:

Revised 10/11/11