Study Collaboration Interest Form

How it Works

We rent Qualified Study Partners up to 30 RipLok devices (locking vape cases )at no charge for 90 days. After the 90 days, you will return the devices to us. If you aren’t able to return a device or your study participant wants to keep it, you’ll owe us $60.

The RipLok iOS App that control the device is downloaded by each of your study participants onto their own phones. They pay $4.99 per month for the app – a total of $14.97 for 90 days. The participant can cancel their app subscription at any time.

Your Organization Information

Your Organization's Name

Company Type

Corporation
University
Other Non-Profit

Your Name

First

Last

Your Job Title

Your Email

Your Phone Number

Your Organization's Mailing Address

Address Line 1

City

State

Zip Code

Type of Study

Please Describe Your Study

Study Location (City & State, or Distributed)

Anticiapted Number of Study Participants

Study Start Date

Funding Status

Fully Funded
In Process for Funding
Not Funded

Your Signature

Clear Signature

Name Type Study

Signature Date