Cytogenetics Resource Request for Animals Form

National Institutes of Health
National Institute of Child Health and Human Development
Distribution of Mouse Models for Chromosomal Disorders

Please fill out this form and click on the "Submit" button once to submit your request. (Attach additional sheets as required)

Date:

 

Name of Principal Investigator:

  

Institution:

  

Address:

 

Phone Number:

 

Fax Number:

 

Email address:

 

Grant or Contract Number & Title, if Applicable:

 

I. Animals Requested.

Strain Name:

  

Number of Mice Requested:

  

Genotype:

 

Sex:

 

Breeding Pairs:

 

Strain Name:

 

Number of Mice Requested:

 

Genotype:

 

Sex:

 

Breeding Pairs:

 

Strain Name:

 

Number of Mice Requested:

 

Genotype:

 

Sex:

 

Breeding Pairs:

 

II. Research Project Description

Please provide a brief description of the research project for which mice will be used. This information is used soley to help us determine the kinds of research for which Resource mice are being used. A synopsis of the information from all users will be used to justify continuation of the Resource. Actual material provided will be confidential.

III. Other Information

A. Optimal Date for Delivery (Approxmiate)
B. Shipping Instructions
C. Arrangements for Pick-up and Transport of Animal from Airport or Other Terminal
D. Billing Instructions
E. Availability of Funds (The Institution should be prepared to submit a purchase order to The Jackson Laboratory prior to shipment)

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This Resource is supported by NICHD/NIH contract #N01-HD-73265.