Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
F108F 14/01/2014 Pagina 1 van 2 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 Active Dried 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 Pagina 2 van 2 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: