CSS-IBST Project: Tracing & Purchase Form
Mycoplasma bovis Eradication Programme
Part A: Buyback Batch Details______________________
The Mycoplasma bovis (M. bovis) Eradication Programme would like to purchase all remaining straws from batches that you hold in your own right, and on behalf of your client
Straws held under your control:
In this section, please list ownership details of straws in the identified batch held under your control.
If a client has given you approval to sell their product and collect payment, this can be indicated by ticking the ‘sale approval’ box below. A copy of your clients written notification allowing you to submit the buyback claim on their behalf will be required before the claim can be processed. Where such approval has been provided, it is your responsibility to reimburse your clients for any of their product which you have sold on their behalf.
Please continue on a separate page if required
Straws not held under your control
In this section, please list details of all your previous sales and transfers of straws, not currently held under your control, that you believe may have formed part of the batches listed in Part A.
Please continue on a separate page if required
Purchaser Name
Part B: Your Details
Ensuring that this information is correct on your first application (or as your details change) will mean that MPI can efficiently register you as a supplier, which will expedite the preparation of Purchase orders and subsequent authorisation of your invoices.
Name (Company director if the claimant is a business)
Full postal address
(Include street number and RD)
City/Region/Province
Trading name (If applicable) Email
If this is your first claim (or your details have changed) please attach:
• either a bank deposit slip, a screen shot of your account including account name and number, or a letter from your bank confirming your account name and number; and
• a completed copy of the MPI New Supplier Form here
Are you GST Registered?
Are you GST
Yes (use GST exclusive prices)
Number Registered?
No (use GST inclusive prices)
Part C: Declaration
I am the legal owner of the property or goods to which this claim applies or have the claimant’s authority to sign (for a company, a current director must sign). I have answered all the questions that apply to me and my application, and the information I have provided is true and correct.
Where straws are not owned by the claimant, I have received express permission from the owner to sell their straws to MPI. I understand that it is my responsibility as the claimant to reimburse clients for any straws that I have sold on their behalf.
I authorise MPI to give or obtain information from any other party that in MPI’s view is relevant to verifying and/or assessing this claim. The purpose being for MPI to be able to efficiently trace product and undertake steps required to ensure timely payment can be made to all owners of straws purchased.
I authorise MPI to pay the assessed amount into the bank account provided with this application.
Your name (print)
Next Steps
Your signature
Date (DD/MM/YYYY)
• We will ensure that you are set up as a supplier with MPI to facilitate payments. This will consist of:
o Ensuring the MPI New Supplier Form (here) is completed; and
o Bank account details provided are verified.
o Clarification if required for details of product to be purchased
• A purchase order will be provided to you for invoicing the approved quantities and values
MPI Contacts
For general information regarding this form, please contact MPI on:
0800 372 767
germplasmimporters@mpi.govt.nz
www.mbovis.govt.nz
Information Security_______________________________________
MPI will store and keep your personal information secure in accordance with the Privacy Act 2020 and any agents working on our behalf will be subject to specified information security and privacy requirements
Before we use personal information or pass it on to anyone else, we will take reasonable and practicable steps to verify the information is accurate, relevant and up to date. You have the right to ask us to correct the information we hold if you think it is not correct.
Further details of MPI Privacy and transparency statement can be found here