Private Strain Deposit

PRIVATE DEPOSIT FORM
Depositor Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Company (if applicable)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
IDENTITY OF STRAIN

Provide as much information as possible as it will help us understand the growth habits of your strain
Scientific name (genus and species)*
Taxonomic class*
Your strain number or strain designation*
Is the strain toxic?*

YesNo
Upload the toxin profile if the strain is toxic

Cancelof
Is the strain axenic?*

YesNo
GROWTH REQUIREMENTS
Culture medium used*
Special growth requirements (for example, ammonia, high light, etc.)
Temperature at which you maintain the strain*
Salinity of the culture medium you use*
Temperature and salinity ranges known*
ADDITIONAL INFORMATION
Collection site and information (be as specific as possible)
Collection date

MonthDayYear
Date
Isolation date

MonthDayYear
Date
How was the strain isolated
Additional Comments
Signature

Clear
Date

MonthDayYear
Date
For office use only
NCMA Private collection #
Should be Empty:

PRIVATE DEPOSIT FORM