Notification of Transferring Living Modified Organisms (Type 2 Use and others)
Year/Month/Date
(Name of the institution of transferee)
(Affiliation, position and name of the transferee)
Mr./Ms.
You are hereby provided with necessary information regarding the transfer of living modified organisms for Type
2 Use in compliance with Article 26 of the “Act on the Conservation and Sustainable Use of Biological Diversity
through Regulations on the Use of Living Modified Organisms” and Article 32 of “Enforcement Regulations of
the Act.”
Name of the recipient organism
or parental organism
□Microorganism・ □Animal ・ □Plant and others
Concrete term (
The information on living modified organisms to be transferred
introduced
)
)
(Class
Name of the donor organism
Name of nucleic acid
(Class
)
Classification of the nucleic acid
Name of the gene
Classification of proliferation
prevention measures
Approval number and approval
date of experiment plan issued
by the organization to which
Approval number
Approval Date
Year/Month/Date/
the assignor belongs
Whether ministerial
□necessary ・ □unnecessary (If necessary, confirmation is required to
confirmation is required
be made in advance by the institution to which the transferee belongs)
Scheduled transfer date
Year/Month/Date
Other information (Information
which is necessary to be provided to
the transferee in order to implement
appropriate treatment to the living
modified organisms)/If Article 16
item 1, 2 or 4 of the Enforcement
Regulation is applicable, please
provide the requirements
(Please write N/A if none of these applies )
Institution name
Rikkyo University
Confirmation
Information on the Assignor
□Ikebukuro Campus
Campus
3-34-1 Nishi-Ikebukuro, Toshima-ku, Tokyo Japan 171-8501
□Niiza Campus
1-2-26 Kitano, Niiza, Saitama Japan 352-8558
College, Department and title
Name
TEL & FAX
TEL
FAX
Email
Position
□Professor ・ □Associate Professor
Signature
Please submit a copy to the office of the Rikkyo University Committee for Life Science Research Ethics and Safety
after mutual confirmation by full-time faculty members.