MODEL FILLED IN APPLICATION FORM

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Allan Brown
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1 MODEL FILLED IN APPLICATION FORM FORM I (see rule 14) Application form for access to Biological resources and associated traditional knowledge Part A 1 Full particulars of the applicant (1) Name (a) Full name of the body corporate/ association/ organization as incorporated /registered under the laws of the respective Government (b) Full name of the authorized representative with designation (c) Common Seal/ stamp of the company : ABC International Trade Co. Ltd. : Mr. John : To be affixed (ii) (iii) Enclosures Letter of authorization issued by the Competent Authority to the authorized representative to sign the application or Board s resolution to this effect. Document of incorporation or registration as per the law governing such incorporation or registration Memorandum of Association and Articles of Association, Bye-laws or other such documents Permanent address (a) Complete address with state/province name/ country and pincode/zipcode (b) Telephone number (fixed line) with code (c) Telephone number (mobile line) with code : To be issued and attached as per format given in Annex-I. : A photocopy of the document to be enclosed duly attested by authorized signatory of the company. : A photocopy of the document to be enclosed duly attested by authorized signatory of the company. : No. 42-5, Lane 3999, Changzhong Road, Shnaghai, , China : : (d) address : shanghjayo@gmail.com Address of the contact person / Agent, if any, in India (a) Full Name of the institution / : CMR Company Pvt Ltd., Hyderabad organization (b) Full Name of the authorized : Mr.Prasad Rao 1

2 representative with designation f. Complete address (state and pincode) : No.30,Jubilee Hills, Hyderabad g. Telephone and Fax number with code : h. Mobile number of authorized : representative. i. and website, if any : cmr@gmail.com Enclosures a. Document of authorization in favour of the agent by the applicant b. Photo identity and Address proof of the agent : As per format given under Annex-I to be filled in. : A copy of Aadhaar, Election ID card, Passport duly attested by self. (iv) Profile of the organization (personal profile in case the applicant is an individual). Please attach relevant documents of authentication : Provide complete profile of the entity not exceeding one page (v) Nature of business : Indicate whether Research/ Research and development/ development/ Manufacturing/ Contract services/ Intermediary/ Export/ Marketing/ Others (please specify) Enclosures: In case of commercial nature of : to be enclosed duly attested by self. business, attach copies of proof of relevant permit to engage in and carry on production/ manufacture/other commercial activity, if any. (vi) Turnover of the organization in US$: : USD 500 billion. Details of turnover for the last two years : Attach a copy of self attested financial statements for the last two financial years. 2. Details and specific information about nature of access sought and biological material and associated knowledge to be accessed (a) Identification (scientific name) of biological resources and its traditional use: (a) Please provide the scientific name Pterocarpus santalinus (b) Please provide the common name : Red Sanders : (c) Details of traditional use, if relevant and source of such information : Known information may be filled in. 2

3 (b) (c) (d) (e) Geographical location of proposed collection: Indicate the name of village, Panchayat, Block, Taluk, District & State from where the biological resources is to be collected If the biological resource(s) is to be collected or procured from the Institute/ Organization/ Company/local trader/individual, provide exact contact details (address and contact number) of such supplier. Indicate whether the material is to be sourced from wild or cultivated Description / nature of traditional knowledge (oral / documented): Provide the source of such information (attach photocopies where ever applicable) Any identified individual / community holding the traditional knowledge. Provide full details of the individual / communities Quantity of biological resources to be collected (give the schedule) Specify the Depot/ site from where the Red sanders are to be lifted. Forest Department, Government of Andhra Pradesh Auctioned material : Known information may be filled in. : Known information may be filled in. : MTs (f) Time span in which the biological resources is proposed to be collected : February 2015 March 2015 (g) Name and number of person authorized by the company for making the selection (a) Please provide full details of the person so authorized Enclosures (a) Authorization letter in favour of persons authorized to make the collection / selection of the biological resources. One person : Shri Prasad Rao, Director, CMR Company Pvt Ltd., Hyderabad : As per format given under Annex-I to be filled in. 3

4 (h) (i) (b) Photo identity proof of the person so authorized The purpose for which the access is requested including the type and extent of research, commercial use being derived and expected to be derived from it Whether any collection of the resource endangers any component of biological diversity and the risks which may arise from the access : A copy of Aaadhar / Election ID card / Passport duly attested by self. : Appropriate info. May be incorporated : Not applicable in view of accessing the auctioned material. 3. Details of any national institution which will participate in the Research and Development activities 4. Primary destination of accessed resource and identity of the location where the R&D will be carried out : N.A : N.A. 5. The economic and other benefits including those arriving out of any IPR, patent : N.A obtained out of accessed biological resources and knowledge that are intended, or may accrue to the applicant or to the country that he/she belongs (a) the nature of benefits envisaged : Provide expected benefits in US dollar (b) Investment in research and : Since we are a trading company this development 6. The biotechnological, scientific, social or any other benefits obtained out of accessed biological resources and knowledge that are intended, or may accrue to the applicant or to the country that he/she belongs. 7. Estimation of benefits, that would flow to India / communities arising out of the use of accessed bioresources and traditional knowledge. 8. Proposed mechanism and arrangements for benefit sharing. provision doesn t arise. : N A : 5% of the auctioned amount will be remitted as benefit sharing to NBA : 5% of the auctioned amount will be remitted as benefit sharing to NBA (Please attach MAT under the MTA between applicant and provider of bioresources and or traditional knowledge) 9. Any other information considered relevant : If any may be specified 4

5 Part B Declaration I/ we declare that: Collection of proposed biological resources shall not adversely affect the sustainability of the resources; Collection of proposed biological resources shall not entail any environmental impact; Collection of proposed biological resources shall not pose any risk to ecosystems; Collection of proposed biological resources shall not adversely affect the local communities; I/we further declare the Information provided in the application form is true and correct and I /We shall be responsible for any incorrect / wrong information. Place Name: Mr. John Date: Signed: to be signed by Mr.John Company Seal / stamp: to be affixed below 5

6 ANNEX- I AUTHORISATION LETTER FOR AGENT/REPRESENTATIVE* I/We Mr./Ms./M/s.* hereby authorize Mr./Ms./M/s.* as my/our* agent/representative* to submit an application under Form I/II/III/IV* of the Biological Diversity Rules, 2004, to the National Biodiversity Authority, India (hereinafter referred to as the NBA) for the purpose of obtaining the prior approval as required under the Biological Diversity Act, 2002, for access to biological resources/ knowledge associated with biological resources and/or traditional knowledge/transfer of results of research based on biological resources/application for an IPR/third party transfer of accessed biological resources.* I/We* hereby authorize and declare that all actions committed by the agent / representative* with regard to the above purpose and all communications by the agent/representative* with the NBA in this regard shall bind me/us* entirely. Signature of Applicant (Common seal if applicable) Signature of Agent (Common seal if applicable) Date: Station: Date: Station: Instructions *Strike out whichever is not applicable The signature and seal (wherever applicable) in this authorisation letter must be in original. The NBA shall construe that the signature and seal (wherever applicable) of the agent/representative as being verified and confirmed by the applicant. 6

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