ICSB Mid Coast Mobile

Semen Release Form

2021 Semen Release Form  ICSB Mid Coast Mobile 504 Tamara Circle, Newark De 19711  Fax: (302)533-5176 Email: midcoastmobile@gmail.com This form must be completed by the semen owner, signed and submitted to ICSB Mid Coast Mobile 2 Business days before frozen semen can be released.   If it is not submitted with 2 business days, there will be additional charges: 1 Day notice $125.00 Same Day Notice $200.00 Processing over the Weekend $225.00 Processing over Holiday $250.00 There is NO Guarantee that ICSB MID COAST MOBILE can ship with less than 2 days notice      Date of Request: ___________________ Date to Arrive:_______________ Number of Vials to Ship:_____________  ________________________________________   ____________________________     ______________________ Registered Name Of Dog                                                                Breed                                       Registry & Number  SHIP TO: Vet Name:_____________________________________________________Phone:_________________________                   Facility Name:____________________________________________________________________________                   Address:____________________________________________________________________________________                  City:____________________________State:_______________Country:____________Zip:__________________   Bitch Owner: Name:___________________________________________Phone:___________________________                 Address: _____________________________________________________________________________­­­­________                City:____________________________________State:_____________Zip:________________________________                 Registered Name Of Bitch____________________________________________________________________________               Registry and Number:__________________________________________________________________________  Credit Card Number______________________________________________EXP DATE_____________ Security Code_________ Billing Zip Code: _____________________ Name On Card__________________________________________________ I authorize ICSB Mid Coast Mobile to charge my credit card for tank & processing and Federal Ezpress expenses. I understand that if my credit card is declined the shipment will not be completed. Signature of Card Holder:________________________________________________________________________  Signature Of Semen Owner:___________________________________________________________________________ By signing and submitting this form. I understand that the ICSB Mid Coast Mobile Terms of Service apply to the collection, storage, shipment and use of this semen by me or another person.   I also understand that while semen release expenses are usually paid by the bitch owner, the semen owner is ultimately responsible for all cost in the event that the bitch owner fails to pay all fees.   Print name of Semen Owner:____________________________________ Phone:_______________________ Address:__________________________________________________________________________________ ICSB Mid Coast Mobile Charges: $100.00  tank use and processing fee within the continental USA $150.00 fee for outside the Continental USA. additional charges will be added for any damages or tank used longer than 7 days We use federal Express for shipping to and from facility All prices are subject to change, ICSB terms of Service apply.  Prices Effective June 1,2021