ST-472 Nat'l Ctr for Genetic Resources Preservation Deposit For

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:	ATTN: PVP Coordinator USDA-ARS, National Center for Genetic Resources Preservation 1111 South Mason Street Fort Collins, CO 80521-4500 Telephone: 970-495-3200 Email: Renee.White@ars.usda.gov
Block 1 PVP NUMBER: COMMON NAME: SCIENTIFIC NAME: CULTIVAR(*) *<> Put brackets around the cultivar name to denote a temporary designation
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: _________
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: _______________________
Block 4 Genetically Engineered Organism? YES NO (Optional) Patented Material YES NO If Yes, provide patent application number or Patent Number ____________________________.

Block 5. For Internal Government use only:

PI No. NSSL Serial No.

PVP Examiner ____ _____________________

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 .5 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 (06/2012) designed by the Plant Variety Protection Office Page 1 of 1