Collecton Authorization Form For ICSB Mid Coast Mobile 2021
(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 $265 S$75 E$100 DNA $65_____ 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_____________________________
