General

Is the MATERIAL a type strain?: *
Yes
No

Is the strain genetically modified?*
Yes
No

Growth Conditions

Medium: *

pH: *

Optimal temperature: *

Minimum temperature: *

Maximum temperature: *

Preservation procedure: *

Literature: *

Genbank Accession Number (16S rRNA gene) :

Genbank Accession Numbers (Genome):

Kingdom: *

Phylum: *

Class: *

Order: *

Family: *

Genus: *

Specific Epithet : *

Intraspecific Epithet :

Full Scientific Name: *

Information on provenance of the MATERIAL, relating to the Convention on Biological Diversity (CBD – www.cbd.int/) and Nagoya Protocol on Access and Benefit Sharing (ABS), and other applicable legal requirements for access to the MATERIAL

In order to assure compliance with all legal and regulatory requirements any information which is relevant has to be provided to and assessed and stored by the COLLECTION. Please provide as much detail as possible on the geographical origin, and terms and conditions for use of the MATERIAL as laid down in relevant documents covering the MATERIAL, including material transfer agreements (MTA), prior informed consent (PIC), mutually agreed terms (MAT) or other documents such as collecting- or export permits of landowners etc. – Be aware that if information provided is insufficient to determine whether MATERIAL is in or out of scope of ABS legislation or regulatory requirements, the BRC may have to refuse the MATERIAL.

Geographic origin and sampling

Source (sample)/substrate: * from which the strain was isolated

Country of Origin: * If applicable

Country of origin is not applicable, because:
from the High seas
from region covered by the Antarctic Treaty
other reason, namely

Locality: *

State: *

County:

Coordinates (latitude): *

Coordinates (longitude): *

Elevation:

Sampled by: * Name of the natural person and affiliation, institute, i.e. the legal person/entity on behalf of which the sample was collected

Is the Material in scope of ABS legislation or regulatory requirements?*
Yes
No

Documents providing evidence of legal access in the Country of Origin and providing terms for use of the MATERIAL

Is the original material or the source sample subject to an International Recognized Certificate of Compliance (IRCC, see definition under Part II below)?*
Yes
No

Prior Informed Consent (PIC) or other sampling authorization (e.g., permit)*
Yes
No

Isolation of the strain

Country: *

Locality: *

State: *

Isolation source: * name of the person and affiliation, institute, i.e., the legal person/entity on behalf of which the sample was collected

Other relevant details of strain history : If you did not isolate the strain, please indicate scientists and laboratories which maintained it before you

Hazardous Properties

Risk Group: * assignment: RG1 / RG2* / RG3* [/ RG4*]

The strain is known to be or likely to be pathogenic to: * Humans / Animals / Plants / other

Biological Safety Level recommended for containment: * BSL-1 / BSL-2* / BSL-3* (*) as far as the collection is authorized to accept and maintain them

Conditions for use of the MATERIAL by the COLLECTION and THIRD PARTIES

I refer to the information that I have provided under B and the relevant documents I am providing to the COLLECTION. I agree that the COLLECTION will supply the MATERIAL to THIRD PARTIES under conditions in agreement with that information.: *

I have not provided any information under B and the Material is not in scope of ABS requirements (B.1). I agree that the COLLECTION will supply the MATERIAL to THIRD PARTIES under the model/standard MTA of the COLLECTION and that the COLLECTION can adopt this model/standard MTA at any time.: *

I have not provided any information under B and the Material is not in scope of ABS requirements (B.1). As the DEPOSITOR I herewith agree that the MATERIAL can be used under the following terms and conditions: *

for any lawful purpose in research and education, including development for commercial purposes: *

for any lawful purpose in research and education, but for non-commercial purposes only: *

for any lawful purpose in research and education. Using the MATERIAL for commercial purposes will require prior consent of the Depositor: *

AGREEMENT FOR DEPOSIT IN THE PUBLIC COLLECTION

First Name: *

Family Name: *

Institute/Company: *

Address: *

Postal Code: *

City: *

Country: *

Phonenumber: *

E-mail: *