REPRODUCE LOCALLY. Include form number and date on all reproductions. Form Approved OMB NO 0581-0055
NATIONAL CENTER FOR GENETIC RESOURCES PRESERVATION DEPOSIT FORM
FOR PLANT VARIETY PROTECTION VOUCHER SAMPLE
Domestic Samples: For each seed / tissue culture voucher sample, PVP Office has completed Blocks 1 and 2 of this form. Provide information from Blocks 3 and 4, and submit an electronic copy and hard copy to:
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ATTN: PVP CoordinatorUSDA-ARS, National Center for Genetic Resources Preservation 1111 South Mason StreetFort Collins, CO 80521-4500Telephone: 970-495-3200 Email: Judy.Grotenhuis@ars.usda.gov |
Block 1 PVP NUMBER:
COMMON NAME:
SCIENTIFIC NAME:
CULTIVAR(*) *<> Put brackets around the cultivar name to denote a temporary designation |
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Block 2 APPLICANT (organization, contact person’s name, address, email and telephone): Owner (ST-470, Block 1): _____________________________________ Contact Person’s Name: _______________________________________ Address : ___________________________________________________ ________________________________________________________________ _______________________________________________________________________________ Phone : ______________ Fax: _______________ Email: ____________________ |
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Block 3 SUPPLIER of seed or vegetatively propagated material, if different from Applicant (include organization, contact person’s name, address, email, fax, and telephone): Name: _________________________________________________________________________ Company: ______________________________________________________________________ Address: _______________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Phone: _______________ Fax: _________________ Email: _______________________ |
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Block 4 Genetically Engineered Organism? YES X NO (Optional)
Patented Material YES NO
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Block 5. For Internal
Government use only: PI
No. NSSL
Serial No.
PVP Examiner
____Davis______________________ SEED
SAMPLE DEPOSIT: TISSUE CULTURE DEPOSIT: %
Viable: No.
of Live Plants Received: Date
Tested: Date
Received: Seed
No. in Storage: Date
Received:
Burden and Nondiscrimination Statements |
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0055. The time required to complete this information collection is estimated to average .0929 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. |
ST-472 (02-06) designed by the
Plant Variety Protection Office
Page
File Type | application/msword |
File Title | PLANT VARIETY PROTECTION |
Author | Judy Grotenhuis |
Last Modified By | usda |
File Modified | 2009-05-26 |
File Created | 2009-05-26 |