www.esr.cri.nz
ESR LABORATORY SERVICES
CULTURE DEPOSIT FORM
ESR maintains a culture collection of medically important bacteria
as part of the New Zealand Reference Culture Collection (NZRM)
RESET FORM
ESR USE ONLY – TO BE COMPLETED BY THE NEW ZEALAND REFERENCE CULTURE COLLECTION MEDICAL SECTION
Date culture received:NZRM accession number:
INSTRUCTIONS FOR USING FILLABLE FORMS: In Acrobat
Reader, please complete this form, then save the pdf to your
hard drive. Email this form to
culturecollection@esr.cri.nz
then print it out and attach to your submitted sample.
ESR0338
vers 2.0 OCT 2017
INSTITUTE OF ENVIRONMENTAL SCIENCE AND RESEARCH LIMITED
NEW ZEALAND REFERENCE CULTURE COLLECTION MEDICAL SECTION, Kenepuru Science Centre: 34 Kenepuru Drive, Porirua 5022
PO Box 50348, Porirua 5240, New Zealand T: +64 4 914 0700 F: +64 4 914 0770
Using Acrobat Reader DC, SAVE AS pdf with a new name and email this request form to: culturecollection@esr.cri.nz
DETAILS OF THE CULTURE DEPOSIT
Scientic name of the organism:
Strain numbers / designations used by the depositor:
Other strain or collection numbers:
Is the strain to be deposited the type/neotype strain if the species? Yes No
Please attach reprints or give references when you email this form Reprints/references attached: Yes No
ORIGIN OF THE STRAIN Please give as much information as possible and attach reprints or give references
Source of isolation:
Geographical area:
Isolated by: Date of isolation:
Identied by:
HISTORY OF THE CULTURE If you did not isolate the strain, please indicate as far as possible the sequence of scientists or laboratories which maintained it
before you, and also earlier used names of the strain in the spaces below
NZRM Depositor
Comments (if relevant):
REASON FOR DEPOSIT
Requested by NZRM: Yes No
Production of:
Other:
Assay of:
MAINTENANCE
Medium (attach formula):
Temperature:
Other requirements:
Gaseous requirements:
IS THE STRAIN DANGEROUS TO HEALTH OR ENVIRONMENT?
It is pathogenic for humans Yes No Unknown
Animal species (name):
It is pathogenic for plants Yes No Unknown Plant species (name):
It is pathogenic for animals Yes No Unknown
DEPOSITOR’S NAME AND ADDRESS
Name:
Address:
Do you have any restrictions on distribution of this organism?
Date:Email:
Organisation:
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