ICSB Mid Coast Mobile

Semen Release Form

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2012 Semen Release Form

International Canine Semen Bank Mid Coast Mobile

504 Tamara Circle, Newark De 19711

Phone: (302)294-6776 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 before frozen semen can be released.   Please submit the completed form at least 2 business days before requested shipping date or the following additional charges will apply:  1-day +$75: Same day +$125 (However, there is no guarantee that ICSB Mid Coast Mobile can ship in less than 2 business days.)


Date of Request: ___________________ Date to Arrive:_______________ Number of Vials to Release:_____________ 

________________________________________   ____________________________     ______________________

Registered Name Of Dog                                                                Breed                                       Registry & Number 

SHIP TO: Name:_____________________________________________________Phone:_________________________

                 Veterinary Facility:____________________________________________________________________________



 For Use By: Bitch Owner___________________________________________Phone:___________________________

                Address: _____________________________________________________________________________­­­­________



              Registered Name Of Bitch____________________________________________________________________________

              Registry and Number:__________________________________________________________________________

 Charges_______________ Circle One:         Visa                   Master Card            American Express              Discover

 Billed To:  CC#____________________________________EXP DATE_____________ Security Code_________

 Zip Code: _____________________ Name On Card__________________________________________________

I authorize ICSB Mid Coast Mobile to charge my credit card shipping costs including Federal Express expenses. I understand that if my credit card is declined the shipment will not be completed.

Signature of Card Holder:________________________________________________________________________

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.

Signature Of Semen Owner:____________________________________________Date:________________

Print name of Semen Owner:____________________________________ Phone:_______________________


**Charges: ICSB Mid Coast Mobile will charge shipping tank rental within the continental US of $100 for up to 7 days, and $15 per day after 7 days until the return of the tank: Outside the Continental US, Rental is $150 for up to 14 days and $20 per day for after 14 days. If the tank is not returned in acceptable condition, the replacement cost will be billed on the credit card above.  The full replacement value of the shipping tank will be charged when shipping semen outside the US and reimbursed with the return of the tank in acceptable condition.  Shipping/Handling costs using Federal Express will becharged to the credit card above by ICSB Mid Coast Mobile. Prices subject to change, ICSB Mid Coast Mobile Terms OF Service apply. Prices effective January 1, 2012



ICSB Mid Coast Mobile
504 Tamara Circle
Newark, De 10711
(302)294-6776 Office
(302)533-5176 Fax
(302)593-2684 Cell

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