Embed Size (px)
Citation preview
Page 1 of 8
iz:i&1 ds lkFk layXu fd;s tkus okys vfHkys[k
1- fofuekZrk dh n’kk esa%& fofuekZrk ;k QeZ ds izksizkbVj dk igpku i= ,oa
LFkk;h irk@orZeku irkA ¼oksVj vkbZ-Mh-@vk/kkj dkMZ@isu dkMZ½
2- O;kikj ;k QeZ dk jftLVsª’ku & ¼xqekLrk izek.k i=@QeZ jftLVsª’ku
uacj@th-,l-Vh-,u- uacj½
3- fofuekZrk dh n’kk esa %& iwoZ rhu foRrh; o"kksZ ds ykHk&gkfu LVsVesaV (P/L
Statement), cgh [kkrk (Balance sheet Statement), vkSj vkWfMV fjiksVZA
4- ,d ikliksVZ lkbt QksVks Lo&izekf.kr pLikA
5- 1]000@& ¼,d gtkj :i;s½ dk fMekaM Mªk¶V@pSd ^^lnL; lfpo] e/; izns’k jkT;
tSofofo/krk cksMZ] Hkksiky** ds uke ls ns; gksxkA
Mh-Mh- ua-@pSd ua-@ vkj-Vh-th-,l- ua-
fnukad
cSad dk uke ,oa 'kk[kk
uksV%& vkosnd }kjk QkWeZ&1 ds lanHkZ esa miyC/k djk;s x;s mDr nLrkostksa dks ¼½ ls fpfUgr djsaA
cksMZ dh oSolkbZV ij QkWeZ&1 dk izk:i miyc/k gSA
vkosnd gLrk{kj
¼lhy½
Website : mpsbb.nic.in/........................................................... E-mail : [email protected]/................................................ Phone no. : 0755- 2554539, 2554549/...................................... Address : 26, Kisan Bhawan, 1st floor, Arera Hills, Bhopal 462011/........................................
vkj-Vh-th-,l- ds gsrq [kkrs dk fooj.k fuEukuqlkj gS&
A/c Holder Name Member Secretary, Madhya Pradesh State Biodiversity
Board
Bank Name IDBI Bank
Branch Name Center Point, Housing Board Building, T.T. Nagar,
New Market, Bhopal (M.P.)
S.B. Account No. 030104000235983
IFSC Code IBKL0000030
MICR Code 462259002
ikliksVZ lkbZt QksVks
LogLrk{kfjr pLik
Page 2 of 8
¼fu;e 17 nsf[k,½
(See rule 17)
okf.kfT;d mi;ksx ,oa lacaf/kr ikjaifjd Kku gsrq@tSolalk/kuksa rd igqap@tSfod
lalk/kuksa ds laxzg.k ds fy, vkosnu izk:i
Application form for commercial use and associated traditional knowledge/access to biological resources/collecting of biological resources
Hkkx d
Part A
1.
vkosnd dk iw.kZ fooj.k %
Full particulars of the applicant:
¼i½ uke %
Name :
¼ii½ LFkk;h irk
Permanent address
¼iii½ nwjHkk"k@[email protected] uacj
Contact/Mobile/Landline No.
¼iv½ bZ&esy@osclkbV
Email/ Website
¼iv½ Hkkjr esa laidZ O;fDr@vfHkdrkZ] ;fn dksbZ gks] dk
irk %
Address of the contact person/agent, if any, in India:
¼vi½ O;fDr/laxBu dh :ijs[kk ¼;fn vkosnd dksbZ O;fDr
gks rks O;fDrxr :ijs[kk- d`Ik;k vf/kizek.ku ds fy,
lacaf/kr nLrkost layXu djsa½ %
Profile of the person/organization (personal profile in
case the applicant is an individual. Please attach relevant
documents of authentication):
¼vii½ dkjksckj dh izd`fr ¼O;kikjh@fuekZrk½ %
Nature of business (Traders/Manufacturer) :
Page 3 of 8
¼viii½ Hkkjrh; :Ik;s esa laxBu dk O;kikjorZ %
Turnover of the organization of Indian Rupees:
di;k tkudkjh ifjf’k"V 1 ,e esa nsoas
(Please provide details as per the Annexure 1 –M)
2. igaqp ds fy;s pkgh xbZ izd`fr rFkk tSfod lkexzh vkSj ;k lacaf/kr Kku rd igaqp ds ckjs
esa C;kSjs rFkk fofufnZ"V tkudkjhA
Details and specific information about nature of access sought and biological material and/or
associated knowledge to be accessed.
¼i½ tSolalk/ku dh igpku ¼oSKkfud uke½ ,oa mldk
ikjaifjd mi;ksx %
Identification (scientific name) of biological resources
and its traditional use:
di;k tkudkjh ifjf’k"V 1&,e esa nsoas
(Please provide details as per the Annexure 1 –M)
¼ii½ izLrkfor laxzg.k dh HkkSxksfyd fLFkfr ¼ftlesa
lfEEkfyr gS ch-,e-lh- xzke] tuin rFkk ftyk
vFkok ou {ks= dk fooj.k chV] jsat] oue.My½%
Geographical location of proposed collection (includes BMC, village, janpad & district or forest area- Beat, Range, Division):
di;k tkudkjh ifjf’k"V 1&,e esa nsoas
(Please provide details as per the Annexure 1 –M)
¼iii½ ikjaifjd Kku dk fooj.k izd`fr rFkk mldk
fo|eku fooj.k ,oa mi;ksx ¼ekSf[kd nLrkosth½
Description/nature of traditional knowledge
(oral/documented):
¼iv½ ikjaifjd Kku j[kus okyk dksbZ igpkuk gqvk
O;fDr@dqVaqc@leqnk;%
Any identified individual/community holding the
traditional knowledge:
¼v½ laxzfgr fd, tkus okys tSolalk/ku dh ek=k
Quantity of biological resources is proposed to be collected (give the schedule) :
di;k tkudkjh ifjf’k"V 1&,e esa nsoas
(Please provide details as per the Annexure 1 –M)
¼vi½ le; lhek ftlds Hkhrj tSolalk/ku laxzfgr
fd;k tkuk izLrkfor gS %
Time span in which the biological resources is proposed to be collected:
di;k tkudkjh ifjf’k"V 1&,e esa nsoas
(Please provide details as per the Annexure 1 –M)
Page 4 of 8
¼vii½ dEiuh }kjk laxzg.k djus ds fy;s izkf/kd`r
O;fDr;ksa ds uke vkSj la[;k %
Name and number of person authorized by the company for making the selection:
¼viii½ igaqp dk iz;kstu] ftlds fy, vuqjks/k fd;k x;k
gS ftlesa lfEEkfyr gS vuqla/kku dk izdkj vkSj
foLrkj] mRi= fd;k tk jgk okf.kfT;d mi;ksx
vkSj O;qRi= gksuk izR;kf’kr gS%
The purpose for which the access is requested including the type and extend of research, commercial use being derived and expected to be derived from it:-
di;k tkudkjh ifjf’k"V 1&,e esa nsoas
(Please provide details as per the Annexure 1 –M)
¼ix½ D;k lalk/kuksa ds laxzg.k vFkok mi;ksx ls
tSofofo/krk ds fdlh ?kVd dks [krjk gSA igaqp
ls mRi= gks ldus okys [krjs %
Whether any collection of the biological resource endangers any component of biological diversity and the risks which may arise from the access:
3. mu tSolalk/kuksa ftu rd igaqp dh x;h rFkk
ikjaifjd Kku ds iz;ksx ls leqnk;ksa dks gks ldus
okys lHkh ykHkksa dk izkDdyuA
Estimation of benefits that would flow to communities arising out of the use of accessed bio-resources and traditional knowledge.
4. ykHkksa ds izHkktu dks izLrkfor dh dk;Zfof/k rFkk
O;oLFkkA
Proposed mechanism and arrangements for benefit sharing.
5. D;k vkids fo:) vkt fnukad rd ,oa mlls iwoZ
fdlh Hkh ou vf/kfu;e ,oa vU; vf/kfu;e ds
rgr dksbZ vijkf/kd izdj.k ntZ fd;k x;k gS\
;fn gkW rks mYysf[kr djsaA
If there has been any criminal proceeding /Liability going on against you as per law of the land. If yes, please specify.
Page 5 of 8
6. dksbZ vU; tkudkjh %&
Any other information considered relevant.
fnukad@Date %
LFkku@Place % vkosnd dk Ukke ,oa gLRkk{kj@izkf/kd`r
vf/kdkjh
Name & Signature of the Applicant/* * Authorized Signatory
irk%
Address:
eqnzk%
Seal:
Hkkx [k
Part B
?kks"k.kk
Declaration
eSa@ge ?kks"k.kk djrs gSa fd
I/we declare that
1. izLrkfor tSolalk/kuksa ds laxzg.k ,oa mi;ksx lalk/kukas dh iks"k.kh;rk ij izfrdwy izHkko
ugha iM+sxk]
Collection of proposed biological resources shall not adversely affect the sustainability of the
resource;
2. izLrkfor tSolalk/kuksa ds laxzg.k ,oa mi;ksx ls dksbZ Ik;kZoj.kh; izHkko ugha iM+sxk]
Collection of proposed biological resources shall not pose any risk to ecosystems;
3. izLrkfor tSolalk/kuksa ds laxzg.k ls ikfLFkfrdh ra= iztkfr;ksa rFkk vkuqokaf’kd fofo/krk
lfgr tSofofo/krk ds fy, dksbZ [krjk mRi= ugha djsxkA
Collection of proposed biological resources shall not pose any risk to biodiversity inclusive of genetic,
species and ecosystem levels.
4. izLrkfor tSolalk/kuksa dk laxzg.k ,oa mi;ksx LFkkuh; leqnk;ksa ij izfrdwy izHkko ugha
iM+sxk]
Page 6 of 8
Collection of proposed biological resources shall not adversely affect the local communities;
eSa@ge] dksbZ Hkh Qhl rFkk@;k jk;YVh dk] tks cksMZ ;k tSofofo/krk izca/ku lfefr
}kjk mnxzghr dh tk,] Hkqxrku djus dk opu nsrs gSaA eSa@ge] volwyh; cSad izR;kHkwfr tSls
fd cksMZ fofgr dh tk,a] nsus dk Hkh opu nsrs gSaA
I/we declare that we here by abide to pay any fees or royalty which my levy either by the Board or
Biodiversity Management Committee/s. This will be in the form of non-refundable bank guarantee or as
decided by the Board.
eSa@ge vkxs ?kks"k.kk djrs gS fd] vkosnu i= esa nh xbZ tkudkjh lR; ,oa izkekf.kd gS
rFkk eSa@ge fdlh xyr@vlR; tkudkjh ds fy, ftEesnkj gksaxsA
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.
5- tSofofo/krk vf/kfu;e 2002 dh /kkjk 3¼2½ ds varXkZr gesa fuEu izko/kkuksa dh tkudkjh gS%&
/kkjk 3¼2½&os O;fDr ftuls mi/kkjk ¼1½ ds v/khu jk"Vªh; tSofofo/krk izkf/kdj.k dk
vuqeksnu ysuk visf{kr gksxk] fuEufyf[kr gS] vFkkZr %&
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 the National
Biodiversity Authority under sub section (1) are the following, namely:
¼1½ og O;fDr tks Hkkjr dk ukxfjd ugha gSA
A person who is not a citizen of India;
¼2½ Hkkjr dk ,slk ukxfjd tks vk;dj vf/kfu;e 1961 dh /kkjk 2 ds [kaM ¼30½ esa
ifjHkkf"kr vfuoklh gSA
A citizen of India, who is a non-resident as defined in clause (30) of section 2 of the Income
tax Act, 1961.
¼3½ ,slk fuxfer fudk;] laxe ;k laxBu tks&
A body corporate, association or organization-
¼i½ Hkkjr esa fuxfer ;k jftLVªhd`r ugha gS ;k %
Not incorporated or registered in India; or
Page 7 of 8
¼ii½ rRle; izo`Rr fdlh fof/k ds v/khu Hkkjr esa fuxfer ;k jftLVªhd`r gS] ftlls
mldh ’ks;j iwath ;k izca/k esa dksbZ xSj Hkkjrh; Hkkxhnkjh gSA
Incorporated or registered in India under any law for the time being in force which has any non-Indian participation in its share capital or management.
vr% bl lEca/k esa] ge fuEu ?kks"k.kk izLrqr djrs gSa fd %
In this connection, I am herewith submitting the following declaration:-
ge@gekjh laLFkk tSofofo/krk vf/kfu;e 2002 dh /kkjk 3¼2½ ds izko/kkuksa ds
vUrxZr ugha vkrs gSaA
I / we hereby declare that I / we / “do not fall” under the scope of the provision contained in section 3(2) of the Biological Diversity Act, 2002.
(*Strike out which is not applicable)
fnukad%
Date:
LFkku %
Place:
vkosnd dk Ukke ,oa gLRkk{kj@izkf/kd`r vf/kdkjh * *
Name & Signature of the Applicant/* * Authorised Signatory
irk%
Address:
eqnzk%
Seal:
**;fn vki izkf/kd`r vf/kdkjh gks rks eq[rkjh vf/kdkj ¼Power of attorney in original)
dh ewy izfr miyC/k djk;saA
**If you are a Authorised Signatory please provide power of attorney in original.
izfr]
To,
lnL; lfpo
The Member-Secretary
e/;izns’k jkT; tSofofo/krk cksMZ
Madhya Pradesh State Biodiversity Board
26] fdlku Hkou]
26, Kisan Bhawan,
izFke ry] vjsjk fgYl] Hkksiky&462011
I Floor, Arera Hills, Bhopal- 462 011.
Page 8 of 8
Ikfjf’k"V 1&,e@Annexure 1-M
vkosfnr o"kZ---------------gsrq tSo lalk/kuksa dh igqap@izkfIr dh vuqekfur tkudkjh ,oa okf"kZd VuZ vksoj dh tkudkjh ¼fofuekZrk ds fy;s½
Estimate for Access of Bio-resource for the Year……….(for manufacture)
QkeZ&1] Hkkx & ^d^ ds fcUnq Ø- 1 (viii) ,oa 2 (i, v, vi, viii) esa of.kZr lanHkZ varxZr
fofuekZ.k bZdkbZ LFky dk irk ----------------------------------------------------------------------------------------------------------------------------- o"kZ & -------------------------
Ø-
S. No.
tSo lalk/ku
dk lkekU;
uke
Name of Bio-resource
(local)
tSo lalk/ku
dk oSKkfud
uke
Name of Bio-resource
(Scientific)
tSo lalk/ku
dk Hkkx
Part of
Bioresource
tSolalk/ku izkfIr dk fooj.k rS;kj izksMDV ;fn viw.kZ gS rks dk
izdkj
Detailed of product manufactured
'ks"k cps
tSo
lalk/ku
dk
mi;ksx
Use of left bio-resource
mRikn
dk
foØ;
ewY;
Product Sale Price
xr o"kZ
dk
okf"kZd
VuZvksoj
Annual Turnover
ek=k
¼fd-xzk-½
(Quantity in KGs)
tSo
lalk/ku
Ø; nj
Purchase Price per KG in Rs.
dqy ewY;
Total Value
fdlls izkIr
fd;k] iwjk irk]
Qksu] eksck-
Brought from whom/
address/mob.
viw.kZ mRikn
ikoMj/,DlVªsDV
@vU;
Powder/ Extract etc.
viw.kZ mRikn Ø;
djus okys dk uke
(Sold to name of buyer)
1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13)
1
2
uksV &
1- izR;sd o"kZ ds fy;s i`Fkd ifjf’k"V 1&,e dk mi;ksx djsaA
2- mijksDr dkWye dh tkudkjh T;knk gksus ij vyx izi= esa izLrqr djsaA
3- dkWye uEcj 3 dh tkudkjh Kkr gks rks HkjsaA
4- dkWye uEcj 4 varxZRk lexz ikS/kk] tM] Nky] Qy&Qwy] iRrk vkfn of.kZr djsaA
5- O;kikjh ds iwoZ foRrh; o"kZ ds izekf.kr ykHk gkfu LVsVesaV (P/L Statement),
ogh[kkrk (Balance Sheet Statement), ,oa vkWfMV fjiksVZ nLrkost izLrqr djsaA
daiuh@fofuekZrk@izkf/kd`r izfrfuf/k dk uke
Name of the trader/Company/ manufacturer/
Authorized Representative
