2021 Semen Release Form
ICSB Mid Coast Mobile
504 Tamara Circle, Newark De 19711
(302)533-5176 Email: email@example.com
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:
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
Registry & Number
TO: Vet Name:_____________________________________________________Phone:_________________________
Bitch Owner: Name:___________________________________________Phone:___________________________
Registered Name Of Bitch____________________________________________________________________________
Registry and Number:__________________________________________________________________________
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:____________________________________
ICSB Mid Coast Mobile Charges:
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
use federal Express for shipping to and from facility
All prices are subject to
change, ICSB terms of Service apply.
Prices Effective June