AUTHORIZATION
STUD DOG OWNER'S AUTHORIZATION FOR SEMEN COLLECTION AND FREEZING
This form is required for our files. Please complete this form and sign below, and return to ICSB-MCA at the following address: International Canine Semen Bank - Mobile California P.O. Box 551, Chicago Park, California 95712. I hereby authorize INTERNATIONAL CANINE SEMEN BANK-MOBILE CALIFORNIA to collect, freeze, and store semen on:
Registered Name: _______________________________ DNA profile number: _____________________Breed: ___________________ Registry and Number: _____________________ DOB: _______________
(NOTE: International Canine Semen Bank-Mobile California (ICSB-MCA) agrees to provide storage at an approved canine semen storage center from the above dog as long as the client maintains current payment on the account. Payment is due at the time of collection, unless a monthly payment plan is requested. Late payment is subject to 1% per month (12% APR) interest and $5.00 late fee per month. If the account becomes delinquent after 90 days, it will be placed in inactive status. A charge for reactivation will be made. After 180 days (6 months) of non-payment, the frozen semen is subject to disposal and the account submitted to a collection agency. Accounts must be current in order for frozen semen to be released.)
By signing below, I agree to these conditions.** ________________________________________________Date: _____________ Printed Name of Owner/Co-owner: _________________________________________
Address:___________________________________________________________________________________
Telephone - Home: ____________________ Office: __________________ Mobile: ____________________
Method of Payment (Please circle): Visa MC AE Check Cash Monthly Payment OAC only
Credit Card Number: _____________________________ Expires: _________________
Name on Credit Card: _____________________________________________________
I agree to the above conditions and also understand that if my credit card is declined, or
check is returned for insufficient funds, I will be responsible for additional charges. I
understand that ICSB-MCA cannot guarantee fertility nor successful fertilization.
Signature: _______________________________________________________
**In the event of my death or permanent incapacitation, I transfer all the frozen semen from the
above to:
Name: ______________________________________________________ Phone: ______________________
Address: __________________________________________________________________________________