Frozen Semen Release-Transfer-Disposal Form

"*" indicates required fields

I give permission for the actions regarding the frozen semen specified below to proceed. (please check all that apply):*

Use for insemination at Subzero Canine reproduction

Release semen for insemination at another facility

Transfer of ownership

Transfer of storage location

Semen disposal

Registered Name of Dog*

Call Name

DNA Profile Number*

Registration Number:*

Breed*

Number of breeding units to be released/transferred/used/disposed*

Breeding Unit 1

Collection Date

Number of vials/straws

Cane Number ID

Post Thaw %

Breeding Unit Dose

Breeding Unit 2

Collection Date

Number of vials/straws

Cane Number ID

Post Thaw %

Breeding Unit Dose

Breeding Unit 3

Collection Date

Number of vials/straws

Cane Number ID

Post Thaw %

Breeding Unit Dose

Complete if for Insemination of Bitch

Registered Name

Call Name

Reg #

Breed

Owner

First Last

Phone

Complete if for Shipment and/or Transfer

Facility Name

Phone

Address

Street Address Address Line 2 City State ZIP Code

I Authorize the above Transaction and Certify I am the Legal Owner of the Frozen Semen listed above.

Signature

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Today's Date*

CREDIT CARD AUTHORIZATION

I, the undersigned, authorize SUBZERO CANINE REPRODUCTION to charge my credit card for processing and shipping frozen semen
The charge of $200.00 covers semen preparation. The tank rental fee, which is $500, includes seven days of use. The tank rental fee will be refunded upon return to SUBZERO CANINE REPRODUCTION.
I agree to a daily fee of $25.00 for each day the tank is not returned after the initial week. Additionally, if the tank is not returned within 30 days or is returned damaged, understand that my credit card will be charged a replacement fee of $1,800.00.
I authorize SUBZERO CANINE REPRODUCTION to charge my credit card to ship the tank to the destination address and back to SUBZERO CANINE REPRODUCTION. Charges will vary depending on the destination and delivery type (First Overnight, Priority Overnight, or 2-day shipping).
I understand that if notification of frozen semen release/transfer and tank preparation is made without 72 hours' notice, a rush fee of $250 will be added to the total shipment cost.

Card Holder's Name

First Last

Credit Card #

CVV

Expiration Date

mm/yy

Billing Zip Code

ZIP / Postal Code