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F108F
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ACCESSION FORM FOR PUBLIC DEPOSIT
BCCM™/LMG BACTERIA COLLECTION
BCCM™/LMG use :
Universiteit Gent - Laboratorium voor Microbiologie
LMG accession no.: __________
Date received: _______________
Date accessed: ______________
K.L. Ledeganckstraat 35
9000 Gent BELGIUM
Phone: +32-9-2645108 Fax: +32-9-2645346
Email: [email protected] Website: http://bccm.belspo.be/about/lmg.php
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BCCM™/LMG accepts bacterial strains up to biohazard group 2 as mentioned in the directive 2000/54/EC or its updates.
Fully documented strains are always of greater scientific value; please complete as many items as possible, especially those relating
to the labeling, origin and history of the strain and the information relating to the CBD. If necessary, annexes can be attached.
1. Strain designations
Scientific name of organism and author(s):
Strain status: (neo)type
Yes
No
Depositor's strain reference label:
Accession number in other collections:
GENBANK/EMBL accession number :
2. Origin of the strain
Source of isolation:
Geographical origin (locality, state, country) of sampling:
date:
Isolated by:
date:
Identified by:
date:
If you did not isolate this strain, please indicate the individual or collection from whom you received the strain, the date of receipt, the
scientific name and strain label at the time of receipt, as well as its former history if known:
 from:
date:
name/label:
 from:
date:
name/label:
3. Information relating to the Convention on Biological Diversity (CBD) See also http://www.cbd.int/
Country of origin (no strains can be accepted without this information):
Sampling agreement - Prior informed consent (PIC) : No
Yes
Not applicable
If yes, - reference :
- name and address of the person or organization who issued the PIC:
- details of any agreed benefit sharing or other form of agreement (please attach documents):
4. Recommended conditions for growth and maintenance
Medium (attach formula):
Temperature °C:
Light conditions:
Oxygen relationship:
Special gas requirements:
Special requirements:
ACCESSION FORM FOR PUBLIC DEPOSIT
F108F
14/01/2014
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5. Preservation methods applicable
Cryopreservation:
Yes
No
Unknown
Lyophilisation:
Yes
No
Unknown
Recommended conditions (suspending fluid, cryoprotectant, cooling rate, etc.):
6. Risk assessment of the strain
Is it pathogenic for humans:
Yes
No
Unknown
Is it pathogenic for animals:
Yes
No
Unknown
Is it pathogenic for plants:
Yes
No
Unknown
Hazard group, disease name, symptoms :
The strain has been genetically modified:
Yes
No
If yes, please provide biosafety details (parent strain(s), donor organism(s) of the DNA, etc.):
7. Mutant status
Name and strain number of parent:
Author and date:
Mutated character:
8. The strain has been patented
No
Yes
, patent reference:
9. Special features and applications
10. Restrictions on distribution or Safety precautions
11. AGREEMENT FOR DEPOSIT IN THE PUBLIC COLLECTION
Name of depositor:
Institution:
Address:
Tel.:
Fax:
Email:
I agree to deposit this culture in the public BCCM™/LMG Bacteria Collection. I authorize BCCM™/LMG to
catalogue the strain data and to distribute samples to third parties under the general conditions of the
BCCM™ Material Transfer Agreement and any other conditions if applicable.
Date:
Signature of depositor: