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   <span style="font-family:Arial;color:#ff0000;font-size:10pt;">Please confirm invoicing details with the sponsor and ensure these are correct prior to completion and submission.</span>
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     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 162.85pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">Title of Research</span>
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     <td colspan="8" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 382.95pt; "> <a name="bm_Text3"></a>
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       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
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    <tr style=" height:18.15pt; "> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 162.85pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">HREC Application #</span>
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     <td colspan="3" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 148.45pt; "> <a name="bm_Text5"></a>
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       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
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     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 106.10pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">SSA Application #</span>
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     <td colspan="3" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 128.40pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
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    </tr> 
    <tr style=" height:18.15pt; "> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 162.85pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">SSA Site Name</span>
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     <td colspan="8" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 382.95pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" height:18.15pt; "> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 162.85pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">Site Principal Investigator:</span>
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     <td colspan="3" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 148.45pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 43.15pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">Email:</span>
      </div> </td> 
     <td colspan="4" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 191.35pt; "> 
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       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 425.30pt; "> 
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       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Type of Application : Commercial Studies</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; text-indent: 0pt; padding-left: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Fee </span>
      </div> 
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       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">(exc. GST)</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; text-indent: 0pt; padding-left: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Please Tick</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">New SSA Application – Sponsor Initiated</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style="padding-top: 0pt; text-indent: 0pt; padding-left: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Arial;font-size:10pt;">$4000</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">☐</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Contract Amendment </span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">$400</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">☐</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Review of updated study documentation (e.g. Protocol, PICF, IB etc.)</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">$300</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">☐</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Type of Application : &nbsp;Cooperative Research Group (CRG) Clinical Trials and other Non- commercially sponsored Clinical Trials</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">The single fee covers the life of the study including any amendments received post-approval. Payment of the TGA’s CTN submission fee (and any other relevant CTN fee) is the responsibility of the CRG or PI and not the Institution, and is in addition to this fee.</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Fee </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">(exc. GST)</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Please Tick</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Non – commercially sponsored CTN Clinical Trial SSA review</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">$1000</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">☐</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Non – commercially sponsored clinical trial with no CTN submission </span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">$300</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">☐</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Contract Review Fee</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">This fee applies to the review of ‘non-standard’ research agreements that require site review by an appropriate officer. This fee may be altered to cost recovery at the discretion of the institution.</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Fee </span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">(exc. GST)</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#d9d9d9; width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Please Tick</span>
      </div> </td> 
    </tr> 
    <tr style=" height:34.35pt; "> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 425.30pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Contract Review Fee</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 70.90pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">$500</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">or cost recovery</span>
      </div> </td> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 49.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">☐</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:34.35pt; "> 
     <td colspan="9" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 545.80pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">All fees will be consistent with the SA Health Fee Schedule and may be subject to alteration without notice</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/health+and+medical+research/research+ethics/research+ethics+and+governance+fees" target="_blank"><span class="cstlHyperlink" style="color: #0000ff; font-weight: bold; text-decoration: underline; font-size: 11pt; font-family: Calibri; text-align: left;">https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/about+us/health+and+medical+research/research+ethics/research+ethics+and+governance+fees</span></a>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="9" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;background-color:#bfbfbf; width: 545.80pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:center;padding-left:0pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;font-weight:bold;">Invoicing Details - Incomplete submissions will be returned</span>
      </div> </td> 
    </tr> 
    <tr style=" height:25.20pt; "> 
     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 233.95pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-left:2pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Sponsor Name and ABN</span>
      </div> </td> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 311.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" height:25.30pt; "> 
     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 233.95pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-left:2pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Sponsor Address</span>
      </div> </td> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 311.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" height:31.05pt; "> 
     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 233.95pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-left:2pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Special Invoice Codes as Required by Sponsor <br />(e.g. Purchase Order #, Sponsor Site Code)</span>
      </div> </td> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 311.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" height:24.95pt; "> 
     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 233.95pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-left:2pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Contact Name, Email and Phone</span>
      </div> </td> 
     <td colspan="7" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 311.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
    <tr style=" height:18.15pt; "> 
     <td style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 162.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Site Customer ID #</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">(Shared Services Code)</span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 113.60pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
     <td colspan="4" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 148.85pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">Site Customer Location ID #</span>
      </div> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">(Shared Services Code)</span>
      </div> </td> 
     <td colspan="2" style=" border-left:solid 4px #000000;border-right:solid 4px #000000;border-top:solid 4px #000000;border-bottom:solid 4px #000000;width: 120.50pt; "> 
      <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">&nbsp;</span>
       <span style="font-family:Arial;font-size:10pt;">     </span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlNormal" style=" position: relative; text-align:left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="margin-bottom:5px;background-color:#E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlHeader" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>
  <table cellspacing="0" style="width: 545.80pt; margin-left: -44.25pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" height:41.75pt; "> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;background-color:#f3f3f3; width: 285pt; "> 
      <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Times New Roman;font-size:14pt;font-weight:bold;">Research Governance Application –</span>
      </div> 
      <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       <span style="font-family:Times New Roman;font-size:14pt;font-weight:bold;">SSA Fee Form </span>
      </div> </td> 
     <td style=" border-left:solid 1px #000000;border-right:solid 1px #000000;border-top:solid 1px #000000;border-bottom:solid 1px #000000;width: 260.80pt; "> 
      <div class="cstlDefaultStyle cstlHeader" style="padding-top: 0pt; padding-bottom: 1pt; font-size: 10pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
       &nbsp;
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstlHeader" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Arial;font-size:8pt;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;SSA Fee Form v3.0, 10 June 2021</span>
  </div> 
  <div class="cstlDefaultStyle cstlFooter" style="font-size: 10pt; padding-bottom: 1pt; font-family: Times New Roman; line-height: 1; position: relative; text-align: left;">
   <span style="font-family:Calibri;font-size:22pt;">&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <p style="border-bottom:2px solid #E7EAEF;">&nbsp;</p>  
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