ࡱ > F bjbj 4P } } J ) ) ) 8 a , ) a w ( 3 5 5 5 5 5 5 $ T" $ H Y Y H n 3 3 : , s LO\ ) ^ 0 ! R >% >% s >% s Y Y >% : @ E Identification and archiving request form for enteric bacterial pathogens (Open Cultures) A. Sender detailsName:Designation:Department/ Division:Institute:Address: Mobile:Telephone:FAX:Email:B. Isolatedetailsa1. Source and place of isolation:2. Date of isolation:3. Reference ID/ No.:4. Presumptive identification, if anyC. Patient Details, if applicable1. Age:2. Sex:3. Brief clinical history:D. Any additional information: Declaration: I am submitting an enteropathogenic isolate for consideration for storage in the GTPR facility. I understand that isolate information will be available in the public domain through HYPERLINK "http://www.gtpr.org.in"www.gtpr.org.in site for sharing of the isolate among researchers for non-profit research. I understand that the decision to add to the collection will be made by Curator of the collection and informed to me. I also understand that if the isolate is stored in the collection it will be maintained using the best available technique. If by any chance the isolate is lost/ damaged the GTPR will not be responsible. Signature with date and seal: Send the request to: Director, National Institute of Cholera and Enteric Diseases P33 CIT Road, Scheme XM, Beliaghata, Kolkata 700010, India Attn. Dr. Asish Kumar Mukhopadhyay, Scientist E For further information, contact: Email: asish1967@gmail.com and hemantakoley@hotmail.com Scanned version of signed copy through Email is also accepted aPlease indicate source of the strain- broadly under Clinical or Environmental group with specific types of source diarrheal stool, or food materials or water bodies etc. Please provide strain identity number under Reference ID/ No. row; this number will be referred while sending identification details to you. A National Facility Supported by ICMR, New Delhi, P-33, C.I.T. 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