■ 유전자원의 접근ㆍ이용 및 이익 공유에 관한 법률 시행규칙 [별지 제3호의2서식] <신설 2018. 12. 27.>

Application Form for Verifying the Conclusion of

Mutually Agreed Terms

※ Please read the instructions below and place a √ in the applicable [  ]

Registration No.

Registration Date and Time

Processing Period: 15 days

Applicant

① Name(The Corporate Representative)

② Affiliation(The Corporate Name)

③ Date of Birth (The Corporation Registration Number)

④ Contact Number

(Phone)

(Email)

⑤ Address(The Location of Its Place of Business)

Serial Number of Declaration Certificate for Access to Domestic Genetic Resources

Mutually Agreed Terms

⑥ Contents of Mutually Agreed Terms

[  ] Monetary Benefit Sharing  [  ] Non-monetary Benefit Sharing

[  ] Conditions for Later Use by Third-Party  [  ] Conditions for Changes in Utilization

[  ] Conditions for Reporting or Information Sharing Between Provider and user

[  ] Applicable Jurisdiction, Governing Law of Dispute Settlement Procedure, and Alternative Dispute Resolution(Mediation, arbitration, etc.)

[  ] Miscellaneous (                                                               )

I hereby submit this Application Form for Verifying the Conclusion of Mutually Agreed Terms in accordance with the former part of Article 4(4) of the Enforcement Decree of the Act on Access to and Utilization of Genetic Resources and Benefit-Sharing and Article 3(3) of the Enforcement Rule thereof.

[Month] [Day] [Year]            .      .        .

Applicant                      (Sign or Seal)

To: (Head of Competent National Authority)

Documents to be submitted by Applicant

A copy of Mutually Agreed Terms

No

Fee

Instructions

1. If the applicant is a corporation, please state the name of corporate representative in column ①; the corporate name in column ②; the corporation registration number in column ③; and the location of its place of business in column ⑤.

2. If the relevant details exits in Mutually Agreed Terms, please place a tick in column ⑥ Contents of Mutually Agreed Terms.

Administrative Process

Completing Form	□	Receiving Form	□	Reviewing Form	□	Making a Decision	□	Issuing a Certificate

210mm×297mm[백상지(80g/㎡) 또는 중질지(80g/㎡)]