BELGIAN COORDINATED COLLECTIONS OF MICROORGANISMS
BCCM/LMG-COLLECTION
Form BCCM/LMG/BP/13/................ Request for the furnishing of samples of deposited microorganisms pursuant to Rule 11.32 (b) (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 11.3 (b)

Form BCCM/LMG/BP/13/................ to be completed in duplicate (number to be filled in by IDA)

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

Send to:
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:




Name of the depositor:
(to be indicated if known to the requesting party)




Identification reference given by the depositor:
(to be indicated if known to the requesting party)




Taxonomic designation, if any, proposed by the depositor:
(to be indicated if known to the requesting party)




II. 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.

III. Requesting 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: