FORM BP11 LMG

BELGIAN COORDINATED COLLECTIONS OF MICROORGANISMS
BCCM/LMG-COLLECTION
Form BCCM/LMG/BP/11/................ Request for the furnishing of samples of deposited microorganisms pursuant to Rule 11.2 (ii) (Fill out in duplicate)

Budapest Treaty of 28 April 1977 on the International Recognition of the Deposit of Microorganisms for the Purposes of Patent Procedure.
Request for the furnishing of samples of deposited microorganisms pursuant to Rule 11.2 (ii)
Form BCCM/LMG/BP/11/................ to be completed in duplicate (number to be filled in by IDA)

(General remark: Always mark the applicable (or boxes) with a cross)

: Belgian Coordinated Collections of Microorganisms (BCCM)
Laboratorium voor Microbiologie - Bacteriënverzameling (LMG)
Universiteit Gent
K.L. Ledeganckstraat 35
B-9000 Gent, Belgium

The undersigned authorized party hereby requests the furnishing of a sample of the microorganism identified hereunder, in accordance with Rule 11.2 (ii) of the Regulations under the Budapest Treaty

I. Identification of the microorganism:

Accession number of the deposit:

II. Declaration of the depositor

The undersigned depositor of the microorganism identified under I above hereby authorizes the furnishing of a sample of the said microorganism to the party specified under IV below.
Name:
Address:
Signature:
(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)).
Date:

III. Request for information

The undesigned authorized party

requests

does not request

an indication of the conditions which the international depositary authority employs for the cultivation and storage of the microorganism.

IV. Authorized party

Name:
Address:
Signature:
(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)).
Date: