Request Form

Page 1

Annex 2. Request for the Distribution of Genetic Resources (DNA)

To: The Director of the Mediterranean Forest DNA Bank

Date: ____________________ Name of Applicant ____________________________ Affiliation / Organization ______________________________________________

Public organization or equivalent Department/Institution

Others (Private company, etc.)

___________________________________

Address ________________________________________________ ________________________________________________ Country ___________________ Postal code _______________ Tel. ___________________ Fax ___________________ E-mail ___________________

I hereby apply for the distribution of the following genetic resources (DNA): ___________________ ___________________ ___________________ ___________________ ___________________ Title of research ___________________________________________________________________ ___________________________________________________________________

Recent publication ___________________________________________________________________ ___________________________________________________________________

Attached Sheet to subscribe conditions for distribution of Genetic Resources (DNA)


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