Plant Material Introduction Request Form

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CANDIDATE MATERIAL INFORMATION

Name of Candidate Material

Type

Plant species and/or common name

Country of Origin

Source

Location where material is being sent from

Accession ID Number

if known

DECLARATION OF GENETICALLY MODIFIED ORGANISM STATUS

Please indicate whether the Material to be submitted for the contracted service has been genetically modified. Note that the CPCNW will not receive genetically modified plant material that has not, at time of submission, been deregulated by USDA-APHIS Biotechnology Regulatory Services.

Has this plant been genetically modified?

No, the plant material has NOT been genetically modifiedYes, the plant material HAS been genetically modified

Has this plant been deregulated by USDA-APHIS BRS?

No, the plant has NOT been deregulatedYes, the plant HAS been deregulated

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DECLARATION OF OWNERSHIP STATUS

Please indicate the ownership status of the Material to be submitted for the contracted service. Where applicable, please provide issued U.S. Plant or Utility Patent or U.S. Plant Varietal Protection (PVP) numbers, or application numbers. Note that the CPCNW will not recognize non- U.S. Plant or Utility Patents or non-U.S. Plant Varietal Protection / Plant Breeder’s Rights.

Which of the following best represents the ownership status of your material? (select all that apply)

Material that has a valid and current U.S. Plant or Utility Patent (USPP)Material that has a valid and current U.S. Plant Varietal Protection (PVP)Material for which an application for a U.S. Plant or Utility Patent (USPP) or U.S. Plant Varietal Protection (PVP) has been made, but not issued.Material that has not, at time of submission, been protected by U.S. Plant or Utility Patent (USPP) or U.S. Plant Varietal Protection (PVP), or Material for which the Sponsor has not applied for and received a USPP or PVP application number.Material that is in the public domain, such as historic or heirloom cultivars, or germplasm for which the relevant U.S. Plant or Utility Patent (USPP) or U.S. Plant, Varietal Protection (PVP) has expired.

Valid and Current USPP No.

Valid and Current PVP No.

USPP or PVP Application No.

CONTRACTED SERVICE REQUESTED

The contracted service requested to be performed on the Material defined in Section 1:

Initial Diagnostics:

Submission of Material to be propagated in CPCNW facilities as per CPCNW standard operating procedures in effect at the time of performance.

Diagnostic PCR testing and high-throughput sequencing to determine pathogen infection status on domestic or imported Material, conducted as per CPCNW standard operating procedures in effect at the time of performance.

Virus Elimination:

One (1) attempt at virus elimination of pathogens detected in Material held at CPCNW that has undergone the Initial Diagnostic contracted service. Virus elimination will be performed using crop-specific methodology conducted as per CPCNW standard operating procedures in effect at the time of performance.

Confirmation of the success or failure of the attempt will be conducted as per CPCNW standard operating procedures in effect at the time of performance.

A maximum of two (2) consecutive attempts at virus elimination may be made, each requiring submission of a new contract and payment fees.

Final Diagnostics:

Diagnostic PCR testing and high-throughput sequencing on domestic or imported Material held at the CPCNW that either i) tested negative for targeted pathogens during the contracted service, or ii) contained pathogens that were successfully removed during the Virus Elimination contracted service.

Diagnostic testing will be conducted as per CPCNW standard operating procedures in effect at the time of performance.

Based on the descriptions above, which contracted service are you requesting? (select only one)

Initial DiagnosticsVirus EliminationFinal Diagnostics

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SPONSOR CONTACT INFORMATION

Name of Sponsor

Contact Person for Sponsor

Sponsor's Email Address

Sponsor's Mailing Address

Sponsor's City

Sponsor's State/ Province

Do not use abbreviations. Ex. Colorado

Sponsor's Postal Code

Sponsor's Country

Sponsor's Phone Number

Enter digits only

Company ID

Terms and Conditions:
Please review all terms and conditions for Material Introduction Agreements. Sponsors will be asked to sign the agreement upon notice that this request has been accepted.