Regulatiun 12(1) FIRST SCHEDULE THE NATIONAL ENVIRONMENT (ACCESS TO GENETIC RESOURCES AND BENEFIT SHARING) REGULATIONS, 2005 APPLICATION FOR PRIOR INFORMED CONSENT Form: AGR 1 IIwe* hereby further declare that to the best of my/our information, the information given in this application is correct and true and that the prior informed consent will only be used for applying to the competent authority to access genetic resources from Uganda. Date .................... . Signature of applicant .................... . FOR OFFICIAL USE ONLY Application received on ................................................ 20..... . *DeJete whicbever is not applicable • To': ................ :..................... (Lead agency) ...................................... (Local Community) ...................................... (Owner) IIwe* ................................................................................................. . of .......................................... (;dd;;;~;j ........................................... .. hereby apply for prior informed consent to enable me/us to apply to the competent authority to access genetic resources under your ownership/jurisdiction. The prior informed consent is being applied for, for the genetic resources located at ........................................... .................................................... ~ (State location by local council,. village, sub county and district) The prior informed consent is being applied for in respect of the following genetic resources............................................................................................................ ........................................................................................................... IIwe* declare' that I am/we* are' willing to enter into an accessory agreement with you on terms and conditions acceptable to you. 400 "....... 401