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Annexure 4 - Requistion Form Ed 17.05.22

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14 views2 pages

Annexure 4 - Requistion Form Ed 17.05.22

Uploaded by

sathedipak834
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Requisition Form for obtaining microbial cultures from NCIM, CSIR-NCL, Pune

(On Official Letter head of the organization/individual)

To, Date:
NCIM Resource Centre
CSIR-National Chemical Laboratory
Pune – 411008

I/We:

1. Name: Mr/Ms/Dr.----------------------------

2. Designation: Individual researcher/ Affiliated to --------------------------------------- (Name of the


organization)

3. Nationality of requester: Indian /NRI /Foreign

4. Category of organization of requester: Individual/Academic Organization / Start-up/Not-for-profit


organization/ For Profit company

5. Shareholding of company: 100% Indian participation/ Any foreign participation (even less than
1%)

(Tick (ü) appropriate option and cross (X) other)

request following culture/cultures from NCIM:

Sr. No Culture name and NCIM no. Purpose* Scale **

* Purpose: Specify the intended use/application (s). (Do not use general terms like R&D purpose,
scientific work, else request will be rejected).

** Scale of use in- ml, L, Gram, Kg, Acre, lab level, field level- if applicable)

(insert additional rows if required)

I/we hereby declare following:

NCIM, CSIR-NCL
() I/We the requester is/are an Indian national(s).
() I/We am/are an 100% Indian entity with not even 1 % foreign participation. Attached is the Certificate
from Chartered Accountant or Company Secretary certifying the shareholding pattern of our company in
the prescribed format.

() I/We am/are Indian/foreign entity with --------% foreign participation. Attached is the Certificate from
Chartered Accountant or Company Secretary certifying the shareholding pattern of our company in the
prescribed format.

(Tick appropriate option)

We agree to following terms while requesting the culture:

1. In-house microbiology facility and trained microbiologist is available for handling the supplied
culture (s).
2. Culture (s) will be used only for the purposes as stated in above table.
3. Cultures will not be handed over to a third party (within and outside India), without obtaining
prior written permission from NCIM.

I/We testify that the all information provided above is true to our knowledge. If any information is found
to be false or if I/we violate any of the above terms, or use the samples for any other purpose than stated
above I/we will be liable for legal action by CSIR-NCL.

Note: Only regular staff can request. No Students, fellows or temporary staff should request cultures.

----------------------------------------- --------------------------------
Authorized signatory (with seal and stamp) Culture(s) requested by
(HoD/Principal/Manager/CEO/Equivalent)
Name: Name:
Designation: Designation:

NCIM, CSIR-NCL

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