南アフリカ共和国バイオ探索許可申請

PART 1: APPLICATION FOR A BIOPROSPECTING PERMIT

COMMERCIALISATION PHASE OF BIOPROSPECTING PROJECT
Notes on completing form:
1. If you are applying for a bioprospecting permit and you do not intend to export the relevant indigenous biological resources, you need only to complete part 1 of this form.
2. If you are applying for an integrated export and bioprospecting permit, you must complete parts 1 and 2 of this form.
3. If insufficient space is provided in this form, additional information may be included by way of Annexures.

KIND OF PERMIT APPLIED FOR (Tick relevant box)

Bioprospecting permit:

Integrated export and bioprospecting permit:

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PART 1: APPLICATION FOR A BIOPROSPECTING PERMIT

APPLICANT (If applicant is a juristic person complete clause 1 ? 5 below)
1. NAME OF INSTITUTION OR BODY:
2. IS THE JURISTIC BODY REGISTERED IN SOUTH AFRICA?　Y/N
3. IF YES, PROVIDE THE SOUTH AFRICAN REGISTRATION NUMBER OF THE JURISTIC BODY:
4. IF NOT, IN WHICH COUNTRY IS THE JURISTIC BODY REGISTERED AND PROVIDE THE REFERENCE NUMBER:
5. CONTACT DETAILS OF THE JURISTIC BODY:

Name:
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

6. DETAILS OF CONTACT PERSON IN A BODY

Name of contact person:
Capacity:
Identity or Passport No: (Attach a certified copy)
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

(If applicant is a natural person complete clause 6 ? 9 below)
7. APPLICATION BY A NATURAL PERSON

Name of applicant:
Identity or Passport No: (Attach a certified copy)
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

8. IS THE APPLICANT AFFILIATED TO A JURISTIC BODY?　
Y/N

9. IF YES, CONTACT DETAILS OF JURISTIC BODY:

Name of juristic body:
Contact person:
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

The rest of this part to be completed by all applicants
10. NAME AND CONTACT DETAILS OF OTHER COLLABORATORS:

A.

Name:
Identity or Passport No: (Attach a certified copy)
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

B.

Name:
Identity or Passport No: (Attach a certified copy)
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

11. NAMES AND CONTACT DETAILS OF INDIVIDUALS CONDUCTING BIOPROSPECTING PROJECT:

A.

Name:
Identity or Passport No: (Attach a certified copy)
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

B.

Name:
Identity or Passport No: (Attach a certified copy)
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

12. ARE THERE INTERNATIONAL SPONSORS:
Y/N

13. IF YES, CONTACT DETAILS OF INTERNATIONAL SPONSORS

Name:
Contact Person:
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

13. ARE THERE SOUTH AFRICAN SPONSORS:
Y/N

15. IF YES, CONTACT DETAILS OF SOUTH AFRICAN SPONSORS

Name:
Contact Person:
Tel No:
Fax No:
E-mail:
Postal Address:	Physical Address:

INDIGENOUS BIOLOGICAL RESOURCES
16. SET OUT THE TYPE OF INDIGENOUS BIOLOGICAL RESOURCES FOR WHICH A PERMIT IS SOUGHT, THE FAMILY, GENUS OR SPECIES, THE PART OF THE ORGANISM TO BE COLLECTED, THE QUANTITY OF THE RESOURCES TO BE COLLECTED OR OBTAINED AND THE SPECIFIC AREA OR SOURCE FROM WHICH EACH RESOURCE IS TO BE COLLECTED OR OBTAINED.

Type of organism	Family, genus or species (scientific and common names) (if possible)	Part of organism to be collected	Quantity	Full locality data (GIS readings if possible)
Example: Plant	Aloe ferox	Leaves	6 kg	….

PREVIOUS RESEARCH AND APPLICATIONS FOR PERMITS
17. IN RESPECT OF THE INDIGENOUS BIOLOGICAL RESOURCES SET OUT ABOVE, HAS ANY OTHER APPLICATION FOR A PERMIT IN TERMS OF THE ACT OR IN TERMS OF ANY OTHER LEGISLATION BEEN SUBMITTED, EITHER PREVIOUSLY OR SIMULTANEOUSLY WITH THIS APPLICATION? Y/N

18. IF YES.

Granted

Refused

Pending (Issuing authority’s reference number)

19. IF GRANTED

Permit number

Issuing authority

Date of issue

DISCLOSURE OF INFORMATION
20. HAS ALL MATERIAL INFORMATION BEEN DISCLOSED TO ANY PERSON, ORGAN OF STATE OR COMMUNITY PROVIDING OR GIVING ACCESS TO THE INDIGENOUS BIOLOGICAL RESOURCES AND TO ANY IDENTIFIED INDIGENOUS COMMUNITIES WITH TRADITIONAL KNOWLEDGE OR USE OF THE INDIGENOUS BIOLOGICAL RESOURCES?
Y/N

21. SUBSTANTIATE ANSWER ABOVE:

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STAKEHOLDERS
NOTE: If any person, organ of state or community is required to provide or give access to the indigenous biological resources, their consent must be obtained and a material transfer agreement (MTA) in the form of Annexure 7 and a benefit-sharing agreement (BSA) in the form of Annexure 8 must be attached to this application.

22. IDENTIFY THE PERSON, ORGAN OF STATE OR COMMUNITY WHOSE CONSENT IS REQUIRED AND IN EACH INSTANCE INDICATE IF A MTA AND A BSA HAVE BEEN CONCLUDED WITH THEM. THESE AGREEMENTS MUST BE ATTACHED TO THIS APPLICATION.

Access provider
MTA concluded and attached?
BSA concluded and attached?

NOTE: If any indigenous community/ies have been identified, a benefit-sharing agreement (BSA) in the form of Annexure 8 must be concluded with that/ those community/ies and must be attached to this application.

23. STEPS TAKEN TO IDENTIFY INDIGENOUS COMMUNITIES:

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24. DESCRIPTION / NATURE OF TRADITIONAL KNOWLEDGE OR USE (ORAL / DOCUMENTED)

25. DESCRIPTION OF ANY INDIGENOUS COMMUNITIES IDENTIFIED AND IN EACH INSTANCE INDICATES IF A BSA HAS BEEN CONCLUDED WITH THEM AND IF THAT AGREEMENT IS ATTACHED TO THIS APPLICATION.

Indigenous community
BSA concluded?
BSA attached?

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26. HAVE ANY AGREEMENTS BEEN CONCLUDED IN RELATION TO THE INDIGENOUS BIOLOGICAL RESOURCES WITH COLLABORATING PARTIES THAT ARE NOT STAKEHOLDERS IN TERMS OF THE ACT?

Yes	No
If yes, have those agreements been disclosed to-
Yes	No
Access provider
Knowledge holder / provider

27. Is any assistance required from issuing authority to conclude the necessary agreements?
Yes /No

If yes, specify nature of assistance and why.

PROJECT PROPOSAL (Attach)
28. A detailed project proposal must be attached to this application setting out the following ?

28.1. The objectives of the bioprospecting project;

28.2. The benefits that may result from the project;
28.3. The proposed methodology;

28.4. The proposed time-frames (i.e. required period of validity of permit);

28.5 Any relevant environmental considerations including impacts of the collection of the indigenous biological resources and proposed steps to minimise or remedy those impacts;

28.6. Reporting processes;

28.7. Desired outcomes of the project; and

28.8. What will happen to the discarded/ wasted specimens at the end of the study?

29. FEES
Departmental Bank Account Pretoria
ABSA Bank South Africa
Account number: 1044240072 Branch code : 632005
ACCOUNT TYPE: CURRENT
Swift Account : ABSA ZAJJ CPT (OUTSIDE SA)
REFERENCE NUMBER: 00946420 & Depositors Details (i.e. your full name and/or company etc.)
R5 000 application fee paid
Yes /No
If yes (attach copy of invoice)

Signature of Applicant
Date
Capacity

ENDORSEMENT OF JURISTIC BODY, IF APPLICABLE

Name
Signature of duly authorized officer
Date

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