Request for Proposals Attachment 4 Agent Request Form

Updated Oct 25, 2026

A Word document (40 KB) attached to Request for Proposals (RFP) - BARDA Vaccine Medical Countermeasures for Pandemic Influenza Preparedness & Response, from the Office of Assistant Secretary for Preparedness and Response. Due Nov 20, 2026, 5:00 PM (UTC-5).

File name: 05-75A50126R00001_RFP Att 4 Agent Request Form.docx

The full file is for paid members, or buy this bid alone.

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BARDA INFLUENZA AND EMERGING DISEASES DIVISION (IEIDD)

AGENT REQUEST FORM

Reason for Shipment:
Shipping Origin Location:

BARDA INFLUENZA AND EMERGING DISEASES DIVISION (IEIDD)

AGENT REQUEST FORM

Reason for Shipment:
Shipping Origin Location:

Agent (Investigational or Non-Investigational) Request – Please Circle One

Item
Lot Number
Concentration
Quantity

Recipient Address:

Agent Shipment
Completed the section below and send with agent to recipient address listed above

Item
Lot Number
Concentration
Quantity

Shipment Conditions (Check all applicable boxes)
27622501390654908550120015914400134620
Cool Packs Dry IceTemperature Monitor

SignatureDate/ Time Shipped

Agent Receipt Verification
Complete the section below upon receipt and scan this form to BARDA IEIDD (Attention: [email protected])

Item
Lot Number
Concentration
Quantity

Receipt Condition (check applicable boxes)

241935057158128005715IntactDamaged

SignatureDate/ Time Shipped

The beginning of the document. Download the full file to read on.