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09/10/2018

VON SEIDELS Intellectual Property Attorneys Form P26
REPUBLIC OF SOUTH AFRICA
PATENTS ACT, 1978
STATEMENT ON THE USE OF
INDIGENOUS BIOLOGICAL RESOURCES, GENETIC RESOURCES,
TRADITIONAL KNOWLEDGE OR USE
(Section 30(3A) – Regulations 22(1) 67B(4))
OFFICIAL APPLICATION NO. / LODGING DATE / AGENT’S REFERENCE
21 / 01 / 22
FULL NAME(S) OF APPLICANT (S)
71
EARLIEST PRIORITY CLAIMED / COUNTRY / NUMBER / DATE
NOTE: The country must be indicated by its International Abbreviation / 33 / 31 / 32
TITLE OF INVENTION
54

I / Wehereby declare that-

* / 1. / I am / We are the applicant(s) above;
** / 2. / I/we have been authorized by the applicant(s) to make this declaration and have knowledge of the facts herein stated in the capacity as indicated below;
*** / 3. / The invention for which protection is claimed
(a)is based on or is derived from an indigenous biological resource or a genetic resource; OR
(b)is not based on or is not derived from an indigenous biological resource or a genetic resource.
*** / 4. / The invention for which protection is claimed
(a)is based on or derived from traditional knowledge or use; OR
(b)is not based on or is not derived from traditional knowledge or use.
*** / 5. / The invention for which protection is claimed
(a)is co-owned with the local community or individual; OR
(b)is not co-owned with the local community or individual.
DATE: ______
PLACE: ______
SIGNED:
______
For:
Full Name: ______
Capacity: ______

(No legalization required)

Foreign Agent Ref:

*In the case of an application in the name of a company, partnership or firm, delete paragraph1.

**If the applicant is a natural person, delete paragraph 2.

***Delete (a) or (b), whichever is not applicable.