TO BE COMPLETED BY SEMEN OWNER (PLEASE READ 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 (or a picture of the completed and signed form may be emailed to info@caninecryobank.com ) 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 ( or email a picture of the completed and signed form to info@caninecryobank.com )

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.