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: 970-492-7500
Email: PVPCoordinator@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
DOES THE VARIETY CONTAIN ANY BIOTECHNOLOGY EVENTS?

YES

NO

A biotechnology event is defined as a single insertion of a nucleic acid construct into a specific site in a
plant’s chromosome; that is regulated under the U.S. Coordinated Framework for the Regulation of
Biotechnology.

Burden Statement
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.

ST-472 (10/2015) designed by the Plant Variety Protection Office

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REPRODUCE LOCALLY. Include form number and date on all reproductions.

Form Approved OMB NO 0581-0055

USDA’s Nondiscrimination Statement
In accordance with Federal civil rights law and UNSN Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race, color, national origin,
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family/parental status, income derived from a public assistance program, political beliefs, or reprisal or
retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all
bases apply to all programs)N Remedies and complaint filing deadlines vary by program or incidentN
Persons with disabilities who require alternative means of communication for program information (eNgN,
Braille, large print, audiotape, American Sign Language, etcN) should contact the responsible Agency or
USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay
Service at (800) 877-8SS9N Additionally, program information may be made available in languages other than
EnglishN
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form,
AD-S027, found online at http://wwwNascrNusdaNgov/complaint_filing_custNhtml and at any USDA office or
write a letter addressed to USDA and provide in the letter all of the information requested in the formN To
request a copy of the complaint form, call (866) 6S2-9992N Submit your completed form or letter to USDA by:
1) mail: UNSN Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400
Independence Avenue, SW Washington, DNCN 202U0-9410;
2) fax: (202) 690-7442; or
S) email: programNintake@usdaNgovN
USDA is an equal opportunity provider, employer, and lenderN

ST-472 (10/2015) designed by the Plant Variety Protection Office

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