ICSB Mid Coast Mobile

Collecton Consent Form

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This form must be filled out and signed prior to each collection. 

click here to download file

You can click the link above  to download the form then print and fill out prior to collection.   

Or you can go to the bottom of the form below and click print and print the form directly from this site. If you choose to do that then you will need to hit your back button or arrow in order to return to the site. 

Collecton Authorization Form For ICSB Mid Coast Mobile 2012

                (Office use Only    ICSB Dog Number ___________  Lab or Evaluation Number_______________)

Date of Collection_________________

Have We collected this Dog before?_________________

This form is required for our files.  Please complete this form and sign below. I hereby authorize International Canine Semen Bank Mid Coast Mobile to collect, freeze and store my dog's semen or collect and evaluate my dog's semen.

 _________________________________________________________________________________ 

(Registered name of dog)

__________________      _______________________________     ________________________

Date of Birth                                         Registry and Number                 Call Name

_________________      __________________________________________________________

Breed                                       Owner Name_

_________________        _______________________________________________________

DNA #                                     Address

_________________        _______________________________________________________

Microchip #                              City                                         State                             Zip

________________________________      __________________________________________

Phone - Office                                                  Phone - Home

____________________        ____________________    _____________________________

Phone - Cell                             FAX                                        E.mail Address

TERMS OF SERVICE: international Canine Semen Bank Mid Coast Mobile (ICSB_MCM) agrees to collect canine Semen from the above named dog and to store the collected canine semen for as long as the Owner(s) maintains a current payment on the account.  Payment is due at the time collection and on the anniversary of the original registration date of the above named dog regardless of the date on which any subsequent collections or storage occurs for the above named dog. Late payment may be subject to 1% per month (12% APR) interest and a $5.00 late fee per month. If the payment is not received Semen is subject to disposal and the account may be submitted to a collection agency.  All accounts with ICSB-MCM for Owner(s) , including accounts relating to other samples or dogs, must be current in order for frozen semen to be released by ICSB_MCM.

     By signing this Authorization Form, Owner(s) recognizes that frozen semen is a perishable item. Sperm cells will eventually cease living however, no one knows or can predict when this will occur, and it can vary from dog to dog and collection to collection. ICSB-MCM cannot guarantee that frozen sperm cells will be viable at the time =f thawing for insemination. There are many circumstances, beyond the control of ICSB-MCM, that may occur which may cause an insemination or the viability of the semen specimen to fail. ICSB-MCM shall not be held liable for , and cannot guarantee conception from frozen canine semen.

     ICSB-MCM shall exercise reasonable care in storing the semen. Aside from the obligation to exercise reasonable care, ICSB-MCM shall not be responsible for acts or commission or omission by individuals who are not employees of ICSB-MDE, and ICSB-MCM expressly disclaims any such liability.  ICSB-MCM strongly suggest that the Owner(s) use a specially trained veterinarian to conduct inseminations with frozen semen to maximize the chance of a successful breeding.  ICSB-MCM shall not be responsible and will be held harmless for any circumstances or events that are beyond all reasonable control of ICSB-MCM, including acts of God, third party intervention, fire, or any other activity that may cause semen to be negatively affected, including tank failure. ICSB-MCM makes no representation or warranty that a successful whelping will result from any breeding.

     Owner(s) agrees to be bound by and subject to the ICSB-MCM TERMS OF SERVICE, as may be amended from time to time.

                                                               Signature:_____________________________________________________

 ____________________________________________________________________________________________

 Payment:  (Please circle)    Cash Visa                MC    AMEX      Check # _______ total vials Std.______

F $35       C $240      S$75      E$65    DNA $50_____    Extra Vials ($60 per): # ___ x $60 = $______   

Total Charge$___________ Less discount % __ discount $______Final Payment:$____________  

Credit Card number: ___________________________zip code__________ Exp ________CVC ____

Name on Credit Card: _________________________________Signed_____________________________    
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ICSB Mid Coast Mobile
504 Tamara Circle
Newark, De 10711
(302)294-6776 Office
(302)533-5176 Fax
(302)593-2684 Cell
midcoastmobile@gmail.com 

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