<p> STRONGBRIDGE BIOPHARMA</p><p>INVESTIGATOR-INITIATED STUDY APPLICATION FORM</p><p>PRINCIPAL INVESTIGATOR INFORMATION Legal name: Date of application:</p><p>Contact name: Phone:</p><p>Email:</p><p>Address:</p><p>STUDY INFORMATION PLEASE ATTACH A COPY OF YOUR FULL STUDY PROPOSAL Study Title: </p><p>Therapeutic Area: Study Hypothesis: Primary and Secondary Objectives:</p><p>TA 1</p><p>TA 2</p><p>TA 3</p><p>TA 4</p><p>Other: ______Support Requested Please include the type of support, product and/or financial support, including amount/quantities for products.</p><p>Estimated total study budget Please attached a detailed line-item budget</p><p>State estimated timeline for study completion Please include all phases (initiation, recruitment/enrollment, etc.).</p><p>List of attachments to this application (CVs, protocol, budget, IRB approval, etc.):</p><p>Additional Information Relevant to this Proposal:</p><p>Signature of Principal Investigator: Date:</p><p>SECTION BELOW IS FOR INTERNAL USE ONLY GRANT COMMITTEE REVIEW Date Reviewed: COMMITTEE DECISION: APPROVE DECLINE HOLD</p><p>Name and signature of Chief Medical Officer: Reviewer Decision: APPROVE DECLINE HOLD</p><p>Name and signature of TITLE/POSITION: Reviewer Decision: APPROVE DECLINE HOLD</p><p>Name and signature of TITLE/POSITION: Reviewer Decision: APPROVE DECLINE HOLD</p><p>Name and signature of TITLE/POSITION: Reviewer Decision: APPROVE DECLINE HOLD</p><p>STRONGBRIDGE BIOPHARMA: Investigator-Inititated Study Application Form Page 1 Version 2: June 2016</p>