~1~ 8~'UVnr.:Jae'JB'UnJ1(;l. , ~

moroa.: """., uau ""'""""n1'"U;n,,""" 1.;'11,.1.""""""'01 nl1"'"YI1~,bI11""";~111~'h~1a. .~';n,n",?i""toiln" 1unl;, ';lfl.»1'vw1m~1Iil"'","n111"fu""\h" 1"~tl""uU»lIill n~l'\',"l "'~1",.

"rU1. lD

-cl 1 'lit •• ••.•. tt::II Q,J 4 " ~ SI • q """ 0.,1 ~ ,lH'l llJ u~~"'-3f\~ ~'1Jm'1J'l(1-3Y1~YiCJlf1')'tl') IY1'W 'E)\M1Llf) , , , " , .. , (~:;!\J'S"lfJ'1Itl'UtJ\Il)lltJl5(specles)

. ", "V r

O· "411 0 V .• r .., .1 D"" '" '.., •• ~ .;""l~\.nUmu1~~1m u,)~'lJ1'1!1.J/Umu~~v"l\J\1'!J1~1'1!n1'7/'\I1tJ~~tl~\1ltJ'Yl1~Ln~Vl .tlBn1mlilCi ..................................................................................................................•.................... :.

" ,1;i.,!~l'ihfi,:j: " "" '" , , " ..," '., , .f"vr)(t): " " .

iJl~\ll.)l'Vtl ~1JJa~11Ii1Jmh.:j!i11ml(Jn11~Wa.:)nTH il0-1~T\Rh,~~mn\J~~v 1mu (f1l'i~1'i1~/m'i~mn1~u/-KPlJUV'1{1 '1)... ,[nultii1Yl'l'lnl'i " , " " " " " .v od ~1rJQ'¥I~nlf)'u 'nV'l11,J 'V10f)l'i

vhDu·nll fnA Cl tJ llJ..I 4 .

(~:;''lr)VlCl'Y10mn 'J~1'J'J1lJl(;1u, ,,,1-ifm'i

LIST OF COLLECTED SPECIMEN (S)

Collection AreaJs: .Province: , ,.., .1 certify upon my honor that the collected specimen listed below is to be collected/used in .. ,(tl1e bjoprospectinglstudy/research/development) ..for ,..(project title)., , , , , ,.., .

•Materials to be collected Form of Collection quota Duration and Purpose and Process Depositary Office

(Specify what material to collection per collection time Frequency for (Specify the purpose (Specify where thebe collected from field by (Specify in what (Specify the unit Collection why the material was material/s pecimen

using a taxonomic form the species and collection (Specify date or collected and the will be kept)

classification) .: and material will quota for each week or month for 'methodology how it

be collected) specimen/material) collecting, and how will be examined)often to be

collected)

Science Name: Roots 10 plants One time per month Identification of DNA The Collection CentrePachypodium baronii Sequence.using the Department of BotanyCommon Name: dideox ynuclcotide Faculty of ScienceDescription: technique University of A

Name and Signature of Collector:

Date:

Address and Tel:

•.

~ I .ci I~l~Uv~8 ~ __ ~(~1~~~~~~y~~~~~1~~~~I~~~)_

v1lii~t1~----------------------

PRIOR INFORMED CONSENT (PlC) CERTIFICATE

. .This' is to certify mat the undersigned has reviewed the project/research proposal of

~~ and understood the implications of the proposed

. project/research activity on.the study area(s) and its vicinity.

Further, I certify that I have consulted my respective constituents/members and they interpose

no objections whatsoever to the project/research.

This PlC Certificate is issued to support the application of -'--'--_for

bioprospecting/research undertaking in (specify study area/place).

However, the Certificate does not automatically allow the to conduct the

project/research unless the Bioprospecting Agreement between the and the

Department of --' __ is made.

Done this. day of , 20 _at _

c-------------------------)Administering Officer

-- -