1. This agreement must be entered into by an applicant for a permit and any stakeholders identified in terms of the Regulations who provide or give access to indigenous biological resources.
2. If there is more than one stakeholder a separate agreement must be entered into with each stakeholder.
3. If insufficient space is provided in this form, additional information may be included by way of annexures. Alternatively, parties can elect to use their own forms with sufficient space provided for each Regulation, as long as those forms follow the general format of this form.
4. The parties to this agreement must sign the agreement in the space indicated and must initial every other page of the agreement, including any annexures.

Parties to the agreement
1. Recipient of indigenous biological resources, if recipient is a juristic person:
1.1. Name of institution or body: ______________________________________ ____________________________________________________________
1.2. Registration no. of institution or body: ______________________________
1.3. Contact details of institution or body (including postal/physical address, phone, fax and e-mail address): ___________________________________
1.4. Name of contact person in institution or body (attach a certified copy of ID document):___________________________________________________
1.5. Capacity of contact person: ______________________________________

2. Recipient of indigenous biological resources, if recipient is a natural person
2.1. Name of recipient: _____________________________________________
2.2. Identity number of recipient: ______________________________________
2.3. Contact details of recipient (including postal/physical address, phone, fax and e-mail address):____________________________________________

3. Provider of access to indigenous biological resources
3.1. Name: _______________________________________________________
3.2. Capacity: _____________________________________________________
3.3. If entering into agreement in a representative capacity, state name of principal: _____________________________________________________
3.4. Contact details (includes physical/postal address, telephone, Fax and e-mail address):____________________________________________________
4. Indigenous biological resources
The type, quantity and source of indigenous biological resources to which this agreement relates are ?

Type of organism

Family, genus or species scientific and common name) (if possible)

Part of organism to be collected

Quantity (Limitation on the quantity of samples)

Full locality data (GIS readings if possible)











5. Current uses of the indigenous biological resources –
The present potential uses of the indigenous biological resources to be collected are the following –

6. Purpose of export (if applicable)
The indigenous biological resources are to be exported for the following purposes ?

7. Third parties
The recipient may only provide any such indigenous biological resources or their progeny to third parties in terms of the following conditions (fill in detail below) –

The recipient agrees to take every reasonable precaution to prevent the identified indigenous biological resources coming into the possession of any unauthorised third party.

8. Entire Agreement
This agreement constitutes the entire agreement between the parties in regard to the subject matter of this agreement and no addition to, variation or cancellation of this agreement or waiver of any rights under this agreement will be of any force or effect unless reduced to writing and signed by the parties to this agreement.

Signature of a applicant for permit: _____________Date: _______________
Capacity of signatory: _____________________________________________
On behalf of: _____________________________________________________
Signature of access provider of resource: ____________Date: __________
Capacity of signatory: _____________________________________________
On behalf of: _____________________________________________________

Approved by the Minister of Water and Environmental Affairs


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