Application form for access to Biological resources and associated traditional knowledge  
      Download Application Form I [ Hindi]     Download Application Form A [ Hindi]     Download Declaration Under section 3(2) [ Hindi]  
      Download Application Form I [ English]     Download Application Form A [ English]     Download Declaration Under section 3(2) [ English]  
 
1. Full particulars of the applicant
Name : *
Email : *  
Contact/Mobile/Landline No: *
Permanent address : *
Address of the contact person/agent, if any, in India :
Profile of the organization (personal profile in case the applicant is an individual). Please attach relevant documents of authentication) :
Nature of business : *
Turnover of the organization :
 
2. Details and specific information about nature of access sought and biological material and associated knowledge to be accessed
Identification of biological resource(s)

Common NameScientific NameTraditional Use of the Bio-resources#


Geographical location of proposed collection collection (includes District,Nagar Nigam , Nagar Palika, Nagar Panchayat, janpad Panchayat and Gram Panchayat)

DistrictNagar Nigam Nagar PalikaNagar PanchayatJanpad Panchayat Gram PanchayatDelete
Mandsaur NA Mandsaur Shyamgarh Mandsaur MANDSAUR delete


Description/nature of traditional knowledge (oral/documented) :
Any identified individual/community holding the traditional knowledge :
Quantity of biological resources proposed to be collected (give the schedule): (Months of collection) :
Time span in which the biological resources is proposed to be collected: (Complete duration of extraction of bio-resources)
Name and number of person authorized by the company for making the collection :
The purpose for which the access is requested including the type and extent of research, commercial use being derived and expected to be derived from it :
Whether any collection of the resource endangers any component of biological diversity and the risks which may arise from the access :
   
Other Details
Estimation of benefits, that would flow to communities arising out of the use of accessed bio-resources and traditional knowledge :
Proposed mechanism and arrangements for benefit sharing :
Any other information considered relevant :
 
Name of Bio-resource(local): *
Name of Bio-resource(Scientific) : *  
Quantity in KGs : *
Purchase Price per KG in Rs.:
Location of the Godam & its full address: *
 
Location of Proposed Collection
BMC : *
Village : *
Block : *
District : *
Beat : *
Range : *
Division : *






Colllection Duration:
Name & full address of Buyer:
Annual Turnover:
     
   
     
 
Name of Bio-Resource(Local) : *
Name of Bio-Resource(Scientific) : *  
Quantity In(Kg) : *
Purchase Price Per KG in (Rs) :
Name Of Buyer :
Address :
Mobile :
Website :
Location of the Godam & Its Full Address :
 
Detailed of Product Manufactured
Extract etc
Finished Product
Sale Price :
Use Of Left Bio-Resource :
Other Details:
Annual Turnover
     
   
     
Declaration
I/we declare that
  • Collection of proposed biological resource(s) shall not adversely affect the sustainability of the resource(s)
  • Collection of proposed biological resource(s) shall not entail any environmental impact
  • Collection of proposed biological resource(s) shall not pose any risk to ecosystems
  • Collection of proposed biological resource(s) shall not adversely affect the local communities
    I/We declare that we here by abide to pay any fees or royalty which may levy either by Borad or the Biodiversity Management Committee/s. This will be in the form of non refundable bank guarantee or as decided by the Board.
    I/we further declare the information provided in the application form is true and correct and I/we shall be responsible for any incorrect/wrong information
  • I am/we are aware that the section 3(2) of the Biological Diversity Act,2002 states as under:- Section 3(2): The persons who shall be required to take the approval of th National Biodiversity Authority under sub section (1) are the following name:
    1. A person who is not a citizen of India
    2. A citizen of India,who is a non-resident as in clause (30) of section 2 of the income tax Act,1961.
    3. A Body corporate,association or organization
      1. Not incorporated or registered in India in;or
      2. Incorporated or registered in India under any law for the time begin in force which has non-Indian participation in its share capital or management
 
     
     
     
   
   
 
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