REQUEST FOR THE FURNISHING OF SAMPLES OF
DEPOSITED MICRO-ORGANISMS PURSUANT TO RULE
11.2.(ii)
BCCM/LMBP/BP/11
F425C
16/10/2014
Page 1 of 2
BUDAPEST TREATY ON THE INTERNATIONAL RECOGNITION OF THE DEPOSIT OF
MICRO-ORGANISMS FOR THE PURPOSES OF PATENT PROCEDURE
To:
Belgian Coordinated Collections of Micro-organisms (BCCM)
LMBP PLASMID COLLECTION
Ghent University - Department of Biomedical Molecular Biology
Technologiepark 927
9052 Gent - Zwijnaarde
BELGIUM
Form
BCCM/LMBP/BP/11/
.....
(number to be filled in
by IDA)
The undersigned authorised party hereby requests the furnishing of a sample of the micro-organism
identified hereunder, in accordance with Rule 11.2.(ii) of the Regulations under the Budapest Treaty.
I. IDENTIFICATION OF THE MICRO-ORGANISM
Accession number given by the International Depositary Authority:
II. DECLARATION OF THE DEPOSITOR
The undersigned depositor of the micro-organism identified under section I above hereby authorises the
furnishing of a sample of the said micro-organism to the party specified under section IV below.
Name or institution*:
*In case the depositor is a legal entity, the authorised representing person according to BCCM/LMBP/BP/1 is:
Name:
Function:
Address:
Date:
Signature:
III. DECLARATION OF THE AUTHORISED PARTY
The undersigned authorised party declares that
1. during the period of validity of the patent, no samples of the micro-organism or of material that is
derived from the micro-organism will be made available to third parties;
2. during the period of validity of the patent, the sample of the micro-organism or of material that is
derived from the micro-organism will only be used for experimental purposes.
REQUEST FOR THE FURNISHING OF SAMPLES OF
DEPOSITED MICRO-ORGANISMS PURSUANT TO RULE
11.2.(ii)
BCCM/LMBP/BP/11
F425C
16/10/2014
Page 2 of 2
IV. REQUEST FOR INFORMATION
The undersigned authorised party
requests;
does not request
an indication of the conditions which the International Depositary Authority employs for the cultivation and
storage of the micro-organism.
V. AUTHORISED PARTY
Name or institution*:
* Where the signature is required on behalf of a legal entity, the typewritten name(s) of the natural person(s) signing
on behalf of the legal entity should accompany the signature(s).
Name:
Function:
Address:
Date:
Note: This form has to be filled out in duplicate!
Signature: