ブータン王国遺伝資源と関連する伝統的知識アクセス申請

Application for Access to Biological/biochemical resources and/or associated TK

Part A: Description of the Applicant & Access Activity
1. Details of the Applicant:
a) Name:
b) Permanent Address:
c) Address of the contact person/agent if any in Bhutan:
d) Profile of the organization (personal profile in case the applicant is an individual with relevant documents)
e) Identity and responsibilities of all entities and individual persons who will be involved in the activities for which access authorization is requested.
f) A valid PIC reference number (a copy of the valid PIC)

2. A description of the applicant(s) technical and financial capability to conduct the activities for which access authorization is requested.
a) Annual turnover of the organization in Nu/US dollars.
b) Equipments and laboratories relevant to the activity.
c) Description of all previous biological/biochemical resource collection activities in Bhutan or elsewhere.
d) Provide complete information about existing or proposed contracts between the applicant and any third party relating to the use of any information and products resulting from the access activity.

PART B: Project Proposal
3. The project proposal shall among other things include the details and specific information about nature of access sought, and biological material and associated knowledge to be accessed.
a) Identification (scientific name) of Biological resource and its use.
b) Geographical location of proposed collection.
c) Description/nature of traditional knowledge (oral/documented)
d) Any identified individual/community holding the traditional knowledge
e) Quantity of biological resources to be collected with schedule.
f) Provide information on the arrangements made within Bhutan to facilitate the collection mission.
g) Time span in which biological resources is proposed to be collected.
h) Purpose for which access is requested including the type and extent of research, mechanism for sharing of results, commercial use being derived and expected to be derived from it and any other benefits anticipated.
i) Whether any collection of the resource endangers any component of biological diversity and the risks which may arise from the access.
j) Indicate the work plan and time frame within which the project is to be completed.
k) The information included in the Access Application Form including Project/research proposal shall be in sufficient detail to enable the relevant authorities to make a decision whether to grant or refuse Access.

4. Provide information on:
a) the primary destination of the resources and any expected subsequent destinations of the resources.
b) intended distribution/sharing of the accessed resources and list actual or potential
beneficiaries.

5. Details and responsibilities of collaborating national institution/s, scholars, scientists, students, farmers and farmer groups in Bhutan in the field mission and/or its follow-up activities.

6. The economic and other benefits including those resulting from any Intellectual Property rights (IPR) and patent 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.

PART C: DECLARATION
I/we declare that the information in the application form is true and correct, and I/we shall be responsible for any incorrect/wrong information.
Signature ——————————————–Name
———————————————Title
———————————————Date
& place ———————————————-

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