BELGIAN COORDINATED COLLECTIONS OF MICROORGANISMS
BCCM/LMG-COLLECTION
Form BCCM/LMG/BP/10/................ Request for the furnishing of samples of deposited microorganisms pursuant to Rule 11.1 (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 11.1

Form BCCM/LMG/BP/10/................ 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 office hereby requests the furnishing of a sample of the microorganism identified hereunder, in accordance with Rule 11.1 of the Regulations under the Budapest Treaty

I. Identification of the microorganism:

Accession number of the deposit:




II. Declaration

Remark:

References to a "patent" shall be construed as references to patents for inventions, inventors’ certificates, utility certificates, utility models, patents or certificates of addition, inventors’ certificates of addition, and utility certificates of addition.

It is hereby declared that:

patent application

No. :
filed on :
, referring to the deposit of the microorganism identified under I above has been filed with this Office for the grant of a patent and that the subject matter of that application involves the said microorganism or the use thereof

international application (PCT)

No. :
filed on :
, referring to the deposit of the microorganism identified under I above, designates for the grant of a patent the State party to the Patent Cooperation Treaty (PCT) for which this Office is the "designated Office" for the purposes of the said Treaty, and that the subject matter of that international application involves the said microorganism or the use thereof

Such application

is pending before this Office

has led to the grant of patent
No. :
granted on:

the sample of the said microorganism is needed for the purposes of a patent procedure accordance with Rule 11.1(iii)

the said sample and any information accompanying or resulting from it will be used only for the purposes of the said patent procedure

III. Request for information

The undesigned Office

requests

does not request

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

IV. Industrial Property Office

Name :

Address :

Country :

Signature :

Date :