Request for Service (External Users)

Principal Investigator

Department

Institution

Last Name

First Name


Email Address


Address

Address (optional)

City

State

Zip Code

Phone

Fax
 Laboratory Contact Person

Last Name

First Name

Email


Phone


Fax
Veterinarian

Last Name

First Name

Email Address


Phone


Fax

Contact Person for Shipping/Handling

Last Name

First Name

Email Address

Phone

Fax

Material For TestingMice Sample
Mouse identifier (strain name used in the laboratory)
Background genetic strain of mice
Backcross history (generations)
Affected locus (all information will be kept confidential)
    

Nature of genetic manipulation
(check all that apply)

Knockout Knock-in Overexpression
Floxed Cre Others
Tissue distribution of mutation
If Tissue-specific, check all that apply:
Skeletal Muscle Adipose Tissue
Liver Cardiovascular System
Brain Islet b-cells
Bone Pulmonary system
GI System Endocrine System
Immune System Others

                                                 Immune status of mice: Normal   Deficient    Undetermined
                                                 Does exporting institution conduct periodic diagnostic tests on its rodents? Yes    No

Number and location of mice/cages

Control mice,  Experimental mice, Number of cages


Facility and room number where mice are currently housed

Gender
Age Date of Birth
Proposed date of transport Date
Proposed studies

 

   

 Overview Mice2