For: Non-Approved Vendor/Other Institution Animal Transfer

Binghamton University For: Non-Approved Vendor/Other Institution Animal Transfer Protocol # Material Transfer Agreement (MTA) on file? ☐ Contact Sponsored Programs ([email protected])

Before a shipping date can be established the veterinarian must review:  Facility health status report for past year  Summary of health issues (clinical observations) for the past year All incoming animals will be held in quarantine for a period of time. Pathogen testing will be performed and will be charged to the PI. Please contact Theresa ([email protected]) to make arrangements for payment.

Receiving Name: Sending Name: Institution Institution Address: Address:

PI Name: PI Name: E-mail: E-mail: Phone: Phone:

Lab Contact: Lab Contact: E-mail: E-mail: Phone: Phone:

Veterinarian: Veterinarian: E-mail: E-mail: Phone: Phone:

Shipping Contact: Shipping Contact: E-mail: E-mail: Phone: Phone:

Animal Information Species/Strain/Genotype ♂ # Males: ♀ # Females: Age/Weight: : Species/Strain/Genotype ♂ # Males: ♀ # Females: Age/Weight: : Species/Strain/Genotype ♂ # Males: ♀ # Females: Age/Weight: : Species/Strain/Genotype ♂ # Males: ♀ # Females: Age/Weight: :

Immune Status: Special Diet: Housing: Competent Compromised House as Other Binghamton University For: Non-Approved Vendor/Other Institution Animal Transfer shipped

Shipping Information Shipping charges paid by: Sending Institution Receiving Institution

PO #: -or- Credit Card (on file) Transport Vendor: Order #: Number of Crates: Proposed Arrival Date: Click here to enter a date. Return this form to [email protected]