Submission form LABOR FÜR KLINISCHE DIAGNOSTIK GMBH & CO. KG Genetics Customer-No. / Barcode PB 1810 DE-97668 Bad Kissingen Tel +49 971 72020 Fax +49 971 68546 Business Hours: Mo - Fr: 9:00 - 18:00 h, Sa: 9:00 - 13:00 h E-Mail: [email protected]

Clinic address: Owners address: Send invoice to: (stamp or block letters) (block letters only, please) Veterinarian Name: ______Owner

First name:______

Date______of birth: ______(If the invoice should be sent to the owner or submitter, please (Owner/submitter) include their complete address and signature ) Street: ______Vat/ID: ______Please note: Zipcode/city: Address for invoicing and ______signee must be identical Fax/e-mail: ______Fax/e-mail:______Date/Signature:______Courier Tel.: ______Notification: Email Fax Mail Report copy to owner

8105 Certificate 7.56 €

For certificates: 1)The identity of the animal must be confirmed by a veterinarian (specified by Microchip-No, Tattoo-No., Pedigree-No.) 2) Certificates are not issued for partner laboratory services

I have checked the animals identity and confirm that samples are taken from the animals listed below.

Name: ______Signature / stamp veterinarian:______

Patient-ID:______Date of sampling: ______

Please note: Indication of breed is mandatory!

Animal 1 (MANDATORY - please complete using capital letters)

Sample: 0,5 ml EDTA-blood Hair Sex: F M

Name: ______Date of birth: ______

Breed: ______Coat colour: ______

Pedigree-No.: ______Tattoo-No.: ______

Microchip-No.: ______Sample label: ______

Animal 2 (MANDATORY - please complete using capital letters)

Sample: 0,5 ml EDTA-blood Hair Sex: F M

Name: ______Date of birth: ______

Breed: ______Coat colour: ______

Pedigree-No.: ______Tattoo-No.: ______

Microchip-No.: ______Sample label: ______

Animal 3 (MANDATORY - please complete using capital letters)

Probe: 0,5 ml EDTA-blood Hair Sex: F M

Name: ______Date of birth: ______

Breed: ______Coat colour: ______

Pedigree-No.: ______Tattoo-No.: ______

Microchip-No.: ______Sample label: ______

010130040018 Hereditary Diseases € € 8214 8464 CA 35.71 HWSD 35.71 (Cerebellar abiotrophy) (Arabian) (Hoof Wall Separation Disease) (Connemara Pony) 8482 8000 Congenital Myotonia 35.71 HYPP 35.71 (New Forest Pony) (Hyperkalaemic Periodic Paralysis) (Quarter Horse) 8160 8231 EMH 35.71 LFS 35.71 (Equine Malignant Hyperthermia) (all breeds) (Lavender Foal Syndrom) (Arabian) 8454 8061 FIS 35.71 OLWS 35.71 (Foal Immunodeficiency Syndrome) (Fell Pony, Dales Pony) (Lethal White Foal Syndrome) (all breeds) 8137 8138 GBED 35.71 PSSM 35.71 (Glycogen Branching Enzyme Deficiency) (Quarter Horse, Paint Horse) (Polysaccharid-Storage-Myopathy Type I) (All breeds) 8072 8039 H-JEB 35.71 SCID 35.71 (Junctional Epidermolysis Bullosa) (Belgian ) (Severe Combined Immunodeficiency) (Arabian) 8139 8470 HERDA 35.71 WFFS 61.82 (Hereditary Equine Regional Dermal Asthenia) (Quarter Horse, Paint Horse) ( Fragile Foal Syndrom) (Warmblood)

Test combinations 8267 8252 5-Panel-Test 109.24 Combination Arabian 92.44 (PSSM, GBED, HERDA, HYPP, EMH) (CA, LFS, SCID) 8250 8253 Combination Quarter Horse / 100.84 Combination Warmblood 109.24 (PSSM, GBED, HERDA, HYPP) (PSSM, WFFS) 8251 8372 Combination Paint Horse 117.65 Combination Quarab 109.24 (PSSM, GBED, HERDA, HYPP, OLWS) (CA, GBED, HERDA, PSSM, SCID)

Coat colours

8070 8159 Agouti 35.71 Graying* 50.00

8140 8183 Appaloosa Pattern1* 50.00 Pearl* 50.00

8463 8228 Camarillo White - W4* 50.00 Roan Zygosity* 50.00 (breeds upon request) 8174 8148 Champagne 35.71 Sabino-1 35.71

8071 8213 Cream 35.71 Silver dapple 35.71

8227 8417 Dun 35.71 Splashed White 35.71

8048 8130 Chestnut 35.71 35.71

8422 8433 GQ Santana Dominant White W10* 50.00 35.71

If more than one colour is requested we charge 35.71 € for the first colour and 15.01 € for each additional colour (except partnerlabs). Performance

8187 Speed-Gen* 65.13 DNA-Profiling According to ISAG 2006

8507 DNA-Profile (proof of identity, genetic fingerprint) 35.29

8109 Parentage verification (paternity test) each parent 35.29 each offspring 50.42

A DNA profile from each partent is required for analyses of parentage. Please contact the lab prior to submission if only one parent is available for testing.

* Partnerlab

In order to allow breeding club discount for the owner please enclose a breeding club membership confirmation with each sample submission. The invoice cannot be altered subsequently.

Supply orders for veterinarians: Submission forms:

1 6 14 100 160

Serum tubes Swabs with transp.medium Histology containers with Allergy Hygiene 2 6a 110 150 Citrate tubes Swabs without transp.med. formalin General Farm Animal 3 6b 5 170 120 EDTA tubes Container for swabs Feacal containers Genetics Dog Pathology 3a 11 7 190 130 Heparin tubes Container for tubes Urine containers Genetics Cat Equine 4 80 1B 180 140 NaFI tubes Barcodes Eppendorf tubes Genetics Equine Reptiles 10 210 Envelopes large Birds and Small Mammals

General terms and conditions: Prices in Euro excl. VAT; Services offered and prices may be subject to change. Charge is x1.40 if invoice is sent to owner. (exception: combination tests, DNA-profiling and *partnerlab). Samples and anonymised test results can be used for scientific purpose. Please find our complete general terms and conditions of business on www.laboklin.com GB - 013004018 / 1607