FROZEN CANINE SEMEN RELEASE FORM ~ ICSB-MCA/ICSB-OR

This form must be completed by the semen owner and submitted to ICSB-MCA/ICSB-OR before frozen semen can be released. Please submit this form to arrive at least 3 days before requested shipping date. If notice is less than three days, a stat fee will apply as follows: 2-day - +$15: 1-day - +$45: Same day - $55.

Registered Name: ______________________________________________________________________

Breed: ___________________ Registry and Number: __________________________________________

NUMBER OF VIALS TO RELEASE: ___________

SHIP TO: Name: ________________________________________________________ Phone: _____________

      Veterinary Facility: ______________________________________________________________________

      Address: __________________________________________________ Zip/Country Code: _____________

FOR USE BY: Bitch Owner: _______________________________________________ Phone:_______________

      Address: __________________________________________________ Zip/Country Code: _______________

      Registered name of bitch to be bred: ____________________________________________________________

      Reg #_________________________

The semen shipment should be shipped to arrive on or before: __________________________________ (Date)

Charges are to be billed to (Visa, Mastercard, Am Ex) number: ______________________ Exp: ____________

Name on Credit Card: _________________________________________________________________________
(Your credit card will be charged prior to shipment)

This shipment will be insured to cover the shipping tank replacement in the event of damage/loss during shipping. Additional insurance to cover the value of the semen may be purchased at a rate of $0.50 per $100 of insurance. If desired, please indicate the amount you wish to insure the shipment $ ___________