Clinical Development Inquiry | Globyz Clinical Solutions

1

Contact Information

First Name *

Last Name *

Company / Organization *

Job Title

Business Email *

Telephone Number

Country *

Company Website

2

Type of Request

How can Globyz Clinical assist overall? *

Request for proposal (RFP) Need lab & analytical support Initial discussion / strategy session Discuss a potential clinical program Clinical trial feasibility Discuss regulatory strategy Pre-clinical to Clinical Transition guidance Professional / Strategic partnership Other

3

Confidentiality Requirement

Confidentiality agreement is already executed between the parties Please send a standard NDA template to the email provided NDA / CDA is required before detailed discussion (a standard NDA template can be provided) Preliminary discussion only (no confidential details will be shared initially)

4

Program Overview

Can the product or program name be disclosed at this stage? *

Yes No (please use code name or study program)

Product Type *

Current Stage of Development *

Therapeutic Area *

General Indication or Study Title Title / general indication only

5

Services Required

Clinical trial strategy / planning Ethics committee & regulatory submissions Protocol design & development Site selection & management Clinical trial site selection & management Feasibility / Site identification Study start-up Data management Clinical monitoring Biostatistical programming Project management Pharmacovigilance & safety reporting Medical writing Quality Assurance / Audit support Pharmacovigilance / safety reporting Medical monitoring Analytical testing support Clinical trial supply management Regulatory & advisory support Other

6

Preliminary Study Information

Type of Study

Approximate Number of Participants

Approximate Number of Study Sites

Anticipated Study Start

Countries or Regions Being Considered:

Canada United States Europe United Kingdom Asia-Pacific Latin America Global / Multi-region Rest of World Other

Is a sponsor summary or synopsis available?

Yes No NDA required first Will send after NDA execution / contact is established

7

Non-Confidential Program Summary

High-level description of the proposed program and supporting details

8

Preferred Meeting Slot

Preferred Contact Method

Preferred Date

Preferred Time

Time Zone

9

Confirmation and Consent

I confirm that the information provided in this inquiry is accurate to the best of my knowledge * I understand that submitting this inquiry does not create a binding commercial contract but initiates preliminary technical evaluation * I consent to Globyz Clinical contacting me regarding this inquiry and storing submitted information for communication purposes * I would like to receive periodic updates on Globyz Clinical services and industry insights

Planning a Clinical Development
Program?

Confidentiality and Preliminary Notice

Contact Information

Type of Request

Confidentiality Requirement

Program Overview

Services Required

Preliminary Study Information

Non-Confidential Program Summary

Preferred Meeting Slot

Confirmation and Consent

Planning a Clinical Development Program?

Confidentiality and Preliminary Notice

Contact Information

Type of Request

Confidentiality Requirement

Program Overview

Services Required

Preliminary Study Information

Non-Confidential Program Summary

Preferred Meeting Slot

Confirmation and Consent

Planning a Clinical Development
Program?