TO BE FILLED OUT BY SEMEN OWNER (PLEASE READ THE INSTRUCTIONS BELOW)

This form authorizes Canine Cryobank Inc. to:

SEMEN OWNER INFORMATION:

  Owner Name:   
  Owner Telephone:  

 



STUD INFORMATION:

 Registration Number:  
 Formal Name:  
 Call Name:  
 Breed:  
 Number of Units:  
 Collection Date:  
 Canine Cryobank Client #:  

 

 

 

 

 

NEW OWNER/STORAGE FACILITY

 New Owner/Facility Name:   
 Address:  
 City, State, ZIP   
 Country  
 Telephone:  
 Fax:  
 Email:  

 








SPECIAL INSTRUCTIONS:


I authorize Canine Cryobank, Inc. to execute the above indicated actions.

Signature of Semen Owner: _______________________________________________________

Date Signed: _____________________________


INSTRUCTIONS:
This form is filled out by the semen owner to instruct Canine Cryobank Inc. to ship and/or transfer ownership of semen stored at Canine Cryobank.
It must be signed and faxed to Canine Cryobank before any shipment or transfer can occur.

SEMEN OWNER INFORMATION SECTION

    1. OWNER NAME: As the semen owner, your name goes in the Owner Name box.
    2. OWNER TELEPHONE: Type your telephone number in the Owner Telephone box so the Cryobank can contact you with any questions.

STUD INFORMATION SECTION

    1. REGISTRATION NUMBER: Type the dog's registration number here. If not registered, type "None".
    2. FORMAL NAME: Type the dog's formal or registered name here. If no formal name, type "None".
    3. CALL NAME: Type the dog's informal or everyday name here.
    4. BREED: Type the dog breed here.
    5. NUMBER OF UNITS: Select the description that is most appropriate. If needed, you can provide more information in the Special Instructions area.
    6. COLLECTION DATE: Select the most appropriate description. If needed, you can provide more information in the Special Instructions area.
    7. CANINE CRYOBANK CLIENT #: The client number can be found on a yearly storage invoice. If it is not readily available, you can leave this item blank.

NEW OWNER/STORAGE FACILITY

Canine Cryobank needs to know to whom you are transferring semen ownership, or what facility will be the new storage location for your semen.

    1. NEW OWNER/FACILITY NAME: Type the name of the new semen owner or the new storage facility here.
    2. ADDRESS: Type the street address of the new owner or storage facility here.
    3. CITY, STATE, ZIP: Type the city, state, and ZIP or postal code of the new owner or new storage facility here.
    4. COUNTRY: If not the United States, type the name of the country of the new owner or new storage facility here.
    5. TELEPHONE: Type the telephone number of the new owner or storage facility here.
    6. FAX: If known, type the fax number for the new owner or storage facility here.
    7. EMAIL: If known, type the email address of the new owner or storage facility here

SPECIAL INSTRUCTIONS:

Type any additional information or instructions in the box.

FINAL STEPS:

    1. PRINT THE FORM
    2. SIGN THE FORM WHERE INDICATED
    3. DATE THE FORM WHERE INDICATED
    4. FAX THE FORM TO CANINE CRYOBANK, INC. at 760-591-9939

IMPORTANT!
CANINE CRYOBANK CANNOT SHIP OR TRANSFER ANY SEMEN UNTIL WE RECEIVE A COMPLETED TRANSFER FORM.
PLEASE ENSURE THAT YOU HAVE PROVIDED A TELEPHONE NUMBER WHERE THE CRYOBANK CAN REACH YOU IF THERE ARE ANY QUESTIONS.