You are on page 1of 2

PHILIPPINE NATIONAL COLLECTION OF MICROORGANISMS

National Institute of Molecular Biology & Biotechnology (BIOTECH)


University of the Philippines Los Baños UPLB
College, Laguna 4031, Philippines
LABORATORY PROCEDURES
PNCM Forms
END-USE CERTIFICATE (EUC)*

PNCM Form No. F-XXVI-II


**EXAMPLE FOR STUDENTS**
SECTION1: PARTIES CONCERNED

(a) Name of Provider: PHILIPPINE NATIONAL COLLECTION OF MICROORGANISMS (PNCM), .


National Institute of Molecular Biology and Biotechnology (BIOTECH), .
University of the Philippines Los Baños (UPLB) .

(b) Name of Buyer: _______________________________________________________________________


Mr. Juan C. Dela Cruz (STUDENT/GROUP LEADER)
(c) Buyer’s Address: _______________________________________________________________________
City Science and Technology School
_______________________________________________________________________
21 Amorsolo St. Makati City, Metro Manila, Philippines

(d) Name of Consignee: _______________________________________________________________________


Dr. Jose D. Capinpin (RESEARCH ADVISER/SUPERVISOR)
(e) Consignee’s Address:_______________________________________________________________________
Room 201, Pasteur Hall, College of Bacteriology, Philippine Microbiological University,
_______________________________________________________________________
Quezon City, Philippines

(f) Name of End-Users: _______________________________________________________________________


Alex A. Santos, Jamaica O. Reyes (STUDENTS & GROUP MEMBERS)
(g) End-User’s Address: _______________________________________________________________________
City Science and Technology School
_______________________________________________________________________
21 Amorsolo St. Makati City, Metro Manila, Philippines

(h) Specific location(s) where the items will be used (if different from (g)):
________________________________________________________________________
Microbiology Laboratory, College of Bacteriology, Philippine Microbiological University,
________________________________________________________________________
Quezon City, Philippines (WHERE ITEMS WILL BE HELD AND HANDLED)

SECTION2: ITEMS
(a) Description of the item(s) (Scientific name and Accession Number, e.g. E. coli BIOTECH 1634) (b) Quantity
__________________________________________________________________________
E. coli BIOTECH 1634 ________
1
__________________________________________________________________________ ________
__________________________________________________________________________ ________
__________________________________________________________________________ ________
__________________________________________________________________________ ________
__________________________________________________________________________ ________
(use extra sheet of paper if necessary)

(c) Date request signed (to be filled-out by end-user):_________________________________________________


22 April 2017

(d) PNCM Number (to be filled-out by PNCM personnel):_______________________________________________


PHILIPPINE NATIONAL COLLECTION OF MICROORGANISMS
National Institute of Molecular Biology & Biotechnology (BIOTECH)
University of the Philippines Los Baños UPLB
College, Laguna 4031, Philippines
LABORATORY PROCEDURES
PNCM Forms
END-USE CERTIFICATE (EUC)*
SECTION3: COMMITMENT

(a) The item(s) indicated in SECTION2 will be used as:


_____________________________________________________________________________________
Test organism for antimicrobial assay of antioxidants and metabolites derived from local fruits in
_____________________________________________________________________________________
the methodology of Lagman et al., 2001.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

(b) The item(s) indicated in SECTION2 will be disposed as follows:

_____________________________________________________________________________________
Original culture and sub-cultures and contaminated material will be autoclaved at 121°C for 15-30
_____________________________________________________________________________________
minutes (depending on volume of material) before disposal as regular waste material.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

(c) The above-mentioned Item(s) and/or replica thereof will NOT be used for the development, production
and/or use of the weapons of mass destruction (WMD). The item(s) will only be used for civil purpose and
handled only as stated above (SECTION 3a and 3b).

(d) The above-mentioned item(s) will be used by the end-user indicated in SECTION1 only and remain / be
consumed in (laboratory of destination):_____________________________________________________
Microbiology Laboratory, College of Bacteriology
_____________________________________________________________________________________
Philippine Microbiological University, Quezon City, Philippines

(e) We (I) shall not re-sell or re-export the above-mentioned item(s).

(f)  We have been made aware and surely understand the contents of “Notice relating to EUC”. Please
check box if you agree.

Signature by the head / authorized person of the company/organization:

Name of the company/organization, Name and title of signatory in block letters


____________________________________________________________________________________________
City Science and Technology School, DR. JOSEFA C. ESCOLTA, DIRECTOR
Date: _______________________________________________________________________________________
22 April 2017
(If you need to use continuation sheets, each must be signed by the same person who signs this form)

NOTES:
Consignee – the person the cultures will be sent to as specified in Section 1.

*This form is patterned from the EUC Form of Japan Culture of Microorganisms (JCM), RIKEN Bioresource Center, designed by the Ministry of Economy, Trade and Industry
(METI), Japan.