REQUEST FOR SHORT MEMORANDUM

From:

First Name:
Name:
Title/Position:
Company:
Address (Company):
Post Code:
City:
State:
Phone (office):
Phone (home):
Fax:
e-mail:

1. I wish to receive the short memorandum concerning project ref.-n° by s-mail by fax by e-mail , but different to the above business address at the following address (optional):

   Address:
   Post Code:
   City:
   State:

2. i c p guarantees that the facts contained in this form as well as the supplemental request according to par. 4 will be held by i c p in strictest confidence and will not be used for other purposes, especially not transferred to third parties not belonging to i c p group. Nevertheless i c p is authorised within the restrictions of the German data protection legislation, to computerise these data.
3. Together with the requested short memorandum I shall receive from i c p a standardised mandate form which contains my confidentiality obligation as well as the remuneration agreement. i c p starts its activities for me only after receiving the signed mandate. i c p, on its part, reserves the right for itself of not deploying any activity, for instance not to disclose the identity of the concerned project, for instance if this would be contrary to the embargo list of the concerned company; i c p is not committed to justify its decision of not becoming active nor to giving any declaration about it.
4. I need additional information before I am able to evaluate the appropriateness of the project. Therefore I await the call of an i c p partner (optional)

within a few days
preferably the between and o'clock