STESEN PENYELIDIKAN FRIM PASOH (SPSH) INSTITUT PENYELIDIKAN PERHUTANAN MALAYSIA Tel : 03 – 6279 7638 Faks : 03 – 6272 9852
No. Keluaran 2
No. Pindaan 0
Tarikh Kuatkuasa 1 Julai 2015
Muka Surat 1/2
B/SPSH/7.1
APPLICATION FOR PERMISSION TO COLLECT BIOLOGICAL RESOURCES IN PASOH FOREST RESERVE
A. PERSONAL PARTICULARS:
Name: _________________________________________________________________________________________
Citizenship: ____________________________________________________________________________________
Place of Birth: ______________________ Date of Birth: _____________
NRIC/Passport no: ___________________ Expiry Date: _____________
Sex: Male Female*
Home Address: _________________________________________________________________________________
_______________________________________________________________________________________
Postal/Business Address: _________________________________________________________________________
_______________________________________________________________________________________
Email: _________________________________ Tel No: ________________________________________________
B. PROFESSIONAL PASTICULARS:
Occupation: ____________________________________________________________________________________
Organization/Institution: __________________________________________________________________________
________________________________________________________________________________________
Postal Address: _________________________________________________________________________________
Website: ______________________________________________________________________________________
Email: _____________________________ Tel No: ______________________
C. PROJECT INFORMATION:
Title: __________________________________________________________________________________________
Research Output: thesis/dissertation/report/publication*
Purpose: Phd/Msc/Bsc/Diploma/Certificate*
(For thesis/Dissertation only)
Duration: _________________ Proposed Start Date: ______________________
Location of Field work: ______________________________________________
STESEN PENYELIDIKAN FRIM PASOH (SPSH) INSTITUT PENYELIDIKAN PERHUTANAN MALAYSIA Tel : 03 – 6279 7638 Faks : 03 – 6272 9852
No. Keluaran 2
No. Pindaan 0
Tarikh Kuatkuasa 1 Julai 2015
Muka Surat 2/2
B/SPSH/7.1
D.
DETAILS OF BILOGICAL RESOURCES TO BE COLLECTED
SPECIES LOCATION QUANTITY
SCIENTIFIC NAME TYPE OF ORGANISM
E.
UNDERTAKING BY APPLICANT
In the event that my application is successful, I hereby agree the following:
i) To report to the Pasoh Research Management (or other agency I am directed to) before I proceed to do the collection ; ii) I will be wholly responsible for obtaining permits should the collected samples be brought out of Malaysia.
iii) Samples collected will only be used for the above mentioned project. Usage for any other than the approved would require approval from the Pasoh FRIM Research Committee.
Signature of Applicant: ____________________________________ Date: ______________________________
Notes:
Type of organism: Birds, fish, Insect, Reptile, Plant, Leave etc.
* DELETE WHERE NOT APPLICABLE
