One-Time Waiver Request Form

Requestor's Contact Name Requestor's Contact Name First Last
I am a
If a student, list faculty advisor's email address
Check one

Check one University order Medical Center order
Organization
Vendor Contact Information
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
What is your business type? (Corporation, LLC, Proprietorship, etc.)
Under what state is your business organized?
Wholesale price per unit (must provide actual price) $ Dollars . Cents
Manufacturer’s Suggested Retail Price per unit (must provide actual price) $ Dollars . Cents
What product(s) are being requested?
Number of units to be produced (must provide actual number)
Attach image of proposed product

Attach Files
Please provide any other additional information.
Vanderbilt University Fee

Vanderbilt University requires a $50 admin fee CHECK and a signed agreement before the one-time waiver agreement can be approved. Please confirm that you will send payment to Vanderbilt University at the following address:

Attn: Brand Engagement – One-time Agreement
Loews Office Tower
2100 West End Avenue, Suite 1100
Nashville, TN 37203

For additional questions please email brandengagement@vanderbilt.edu.