SWCHSC TRANSGENIC FACILITY

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1. Primary Investigator:

*Name (Last Name, First Name):

*Department :

*Institute:

*Street Address:

*City:

*State/Province:

*Zip/Postal Code:

*Country:

*Phone:

*Fax:

*E-mail:

2. Designated Lab Contact:

Name (Last Name, First Name):

Phone:

Fax:

E-mail:

*3. Service Requested:

Microinjection

ES cell<->embryo aggregation

Genotyping. FedEx account number for sample shipment:

Germline testing

Microinjection and aggregation will be done with CD1 embryos unless other arrangments are made.

*4. Name of transgene construct or ES cell line:

5. Comments on expected expression and / or phenotype:

*6. Billing:

Internal clients - Enter a cost centre:

External clients - Cheques should be made out to Sunnybrook & Women's College Health Science Centre and mailed to C. Lobe, SWCHSC, S-218, 2075 Bayview Ave., Toronto, ON, Canada M4N 3M5.

Do you require an invoice? Yes No

*7. Animal Use Protocol Number (for internal clients):

Items 8-13 are for external clients

8. Institutional Veterinarian/Authorized Shipment Approver at Recipient Institution:

*Name (Last Name, First Name):

*Title:

*Phone:

*Fax:

E-mail:

9. Animal Resource Coordinator/Animal Shipment Contact:

Unless informed otherwise, this individual's contact information will be specified on shipping documents

*Name (Last Name, First Name):

Title:

*Phone:

Fax:

E-mail:

10. Live Animal Shipment Carrier:

Preferred Carrier

11. Broker:

Firm

Fax

12. Ship to Address:

Dept.

Institute

Street Address

City

State/Province

Zip/Postal Code

Country

13. Special Shipping Instructions:

14. Notes/Comments:

 

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Lobe Laboratory