■ 유전자원의 접근ㆍ이용 및 이익 공유에 관한 법률 시행규칙 [별지 제1호의2서식] <신설 2018. 12. 27.>
Report on Access to Domestic Genetic Resources
※ Please read the instructions on the reverse side and place a √ in the applicable [ ]	(Front)
Registration No.	Registration Date and Time	Processing Period: 30 days
Reporting Person	① Name(The Corporate Representative)	② Affiliation(The Corporate Name)
③ Date of Birth(The Corporate Registration Number)	④ Contact Number (Phone) (Email)
⑤ Address(The Location of Its Place of Business)
Provider of Genetic Resources	⑥ Name(The Corporate Representative)	⑦ Affiliation(The Corporate Name)
⑧ Date of Birth(The Corporate Registration Number)	⑨ Contact Number (Phone) (Email)
⑩ Address(The Location of Its Place of Business)
Genetic Resources and Access to and Utilization of Genetic Resources	⑪ Name of the Genetic Resources (Common Name and Scientific Name of the Relevant Species) ( / )	⑫ Quantity or Concentration ([ ] Traditional Knowledge)
⑬ Methods for Accessing the Relevant Genetic Resources [ ] Purchase [ ] Endowment or Exchange [ ] Gene Bank or Seed Bank, etc. [ ] Collection [ ] Access to Genetic Resources through Third-Party by Contract, etc. - Information about Third-Party: (Affiliation / Name of Company) (Name / its Corporate Representative) (Contact Number) [ ] Miscellaneous( )
⑭ Purpose for Accessing Genetic Resources [ ] Commercial [ ] Non-Commercial	⑮ Purpose for Utilization [ ] Pharmaceutical [ ] Cosmetic [ ] Horticulture [ ] Miscellaneous( )
⑯ Country(s) Seeking to Utilize the Relevant Genetic Resources	⑰ Method for Utilizing Genetic Resources	⑱ Period of Utilization
Mutually Agreed Terms	⑲ Whether Mutually Agreed Terms are Concluded [ ] Yes [ ] No	⑳ If not, reasons for Not Concluding
Contents of Mutually Agreed Terms [ ] Monetary Benefit Sharing [ ] Non-monetary Benefit Sharing [ ] Conditions for Later Use by Third-Party [ ] Conditions for Changes in Use [ ] Conditions for Reporting or Information Sharing Between Provider and User [ ] Applicable Jurisdiction, Governing Law of Dispute Settlement Procedure, and Alternative Dispute Resolution(Mediation, arbitration, etc.) [ ] Miscellaneous ( )
I hereby submit this Report on Access to Domestic Genetic Resources pursuant to Article 9(1) of Act on Access to and Utilization of Genetic Resources and Benefit-Sharing, Article 4(1) of the Enforcement Decree thereof, and Article 3(1) of the Enforcement Rule thereof.
[Month] [Day] [Year] . . .
The Reporting Person	(Sign or Seal)
To:	(Head of Competent National Authority)
Documents to be Submitted by the Reporting Person	1. A copy of Mutually Agreed Terms(if concluded) 2. Document that can verify the reporting person’s identification or affiliation(only if the Competent National Authority cannot verify the identification or affiliation of the reporting person as a foreigner by sharing administrative information)	Fee: KRW 10,000
Matters to be Checked by the Head of Competent National Authorities	1. Corporate Registration Certificates(in cases of corporations) 2. Foreigner Registration Certificates(in cases of individuals)
210mm×297mm[백상지(80g/㎡) 또는 중질지(80g/㎡)]

(Back)

Consent to Sharing Administrative Information

I hereby consent that officers in charge of reporting can check matters to be checked above by the Competent National Authorities through sharing administrative information pursuant to Article 36(1) of Electronic Government Act.

※ If the reporting person does not consent to the above, the person must submit the relevant document directly.

The Reporting Person

(Sign or Seal)

Instructions

1. If the reporting person is a corporation, please state the name of  corporate representative in column ①; the corporate name in column ②;the corporate registration number in column ③; and the location of its place of business in column ⑤

2. If the provider is a corporation, please state the name of corporate representative in column ⑥; the corporate name in column ⑦; the corporate registration number in column ⑧; and the location of its place of business in column ⑩.

3. Where the name of a certain genetic resource exists, please state such name in column ⑪ Name of Genetic Resource, along with the scientific name and the common name of the relevant species. If no name of a certain genetic resource exists, then please state only the scientific name and common name of the relevant species.

4. If the reporting person intends to access to a genetic resource, please state quantity or concentration of the genetic resource in column ⑫ and if the reporting person intend to access to traditional knowledge, then it should be ticked.

5. Multiple ticks are permitted in columns ⑬ Methods for Accessing the Relevant Genetic Resources; ⑭ Purpose for Accessing the relevant genetic resources; ⑮ Purpose for Utilization; ⑯ Country(s) Seeking to Utilize the Relevant Genetic Resources; ⑰ Method of Utilizing Genetic Resources; and  Contents of Mutually Agreed Terms.

6. If there is access to the relevant genetic resource through a third-party by contract, etc. (i.e., a procurement agent, etc. other than the provider of genetic resources), provide third-party information additionally in column ⑬ Methods for Accessing the Relevant Genetic Resources. If the third-party is a corporation, please state the name of the corporation and the name of its representative.

7. Briefly describe technology including biological engineering technology applied to the genetic resources, in column ⑰ Method for Utilizing Genetic Resources

8. If you have not concluded the agreement on sharing benefits under Article 11 of the Act on Access to and Utilization of Genetic Resources and Benefit-Sharing ("Mutually Agreed Terms"), please briefly state the reasons as to why no Mutually Agreed Terms were concluded, in column ⑳ If not, reasons for Not Concluding.

※ If Mutually Agreed Terms are concluded ex post facto in accordance with Article 4(4) of the Enforcement Decree of the Act on Access to and Utilization of Genetic Resources and Benefit-Sharing, please submit an Application Form for Verifying the Conclusion of Mutually Agreed Terms and evidencing documents to the head of the Competent National Authority; and a verification certificate will be issued.

9. Only if Mutually Agreed Terms are concluded, please tick in column  Contents of Mutually Agreed Terms; and if the relevant details exist in Mutually Agreed Terms, then they should be ticked.

Administrative Process

Completing Form	□	Receiving Form	□	Reviewing Form	□	Reviewing Acceptance	□	Making a Decision	□	Issuing a Certificate