Inter-Institutional Animal Transfer

INTER-INSTITUTIONAL ANIMAL TRANSFER

Today’s Date______Requested Shipping Date______Please complete form and submit request for shipping at least one week prior to requested shipping date

P.O. or Ref. SHIPPING INSTITUTION # Principal Contact Investigator Veterinarian Kevin C. O’Hair PI Phone # PI Fax Vet Phone # 505 272 3936 Vet Fax # 505 272 9106 Institution University of New Mexico, Health Sciences Center Vet E-Mail [email protected] 915 Camino de Salud Animal Kristy Chavez Address ARF, BMSB G-32, MSC08 4530 Facility Contact Christie Wilcox City Albuquerque Phone # 505 272 3936 Fax # 505 272 9106 [email protected] E-Mail State NM ZIP 87131 [email protected] AAALAC Intl. OLAW USDA IACUC Accredited ? YES Assurance # A-3350-1 Registration # 85-R-0014 Approval #

P.O. or RECEIVING INSTITUTION Ref. # Principal Contact Investigator Veterinarian

Institution Phone # Fax #

E-Mail Address Facility Contact

City Phone # Fax #

State ZIP E-Mail AAALAC Intl. OLAW USDA IACUC Accredited ? Assurance # Registration # Approval #

ANIMAL HANDLING INFORMATION # of Housing location at Housing location at Quantity Species Strain Sex Weight Age Crates shipping institution receiving institution

BILLING INFORMATION

Courier Health Certificate Charge Courier’s Phone # Express Mail Charge

Airbill # Veterinary Time Charge  Bill Shipper Account # Technical Time Charge  Bill Receiver Account # Crate Charge

Pick-up Date Courier Charge

Delivery Date Service Charge

Special Other Charge Handling Instructions TOTAL Transfer of inbred, mutant, or gene targeted animals may require the completion of a Material Transfer Agreement prior to shipment. Contact your institution’s department of grants and contracts for information.