Request for Animals

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National Institutes of Health / National Institute of Child Health and Human Development

*Designates required information

*Email:
Investigator's name:
Institution:
Address:
Phone:
Fax:
Grant or contract number & title, if applicable:

I. Animals requested:

Strain name:
Number of mice requested:
Genotype:
Sex:
Breeding pairs:

Strain name:
Number of mice requested:
Genotype:
Sex:
Breeding pairs:

Strain name:
Number of mice requested:
Genotype:
Sex:
Breeding Pairs:

II. Research project description:

Brief explanation of research project for which mice will be used. This information is to help us determine the kinds of research for which the mice are being used. A synopsis of the information from all users will be used to justify continuation of the Resource. Actual material provided will be confidential.

III. Other information:

A. Optimal date for delivery (approximate)

B. Shipping instructions

C. Arrangements for pick-up and transport of animal from airport or other terminal

D. Billing Instructions

E. Availability of funds (The institution should be prepared to submit a purchase order to The Jackson Laboratory prior to shipment)

Please review the data in the form above. If you would like to edit your submission, please do so before submitting your form. We encourage you to print a copy of this page (before submitting) for your records.

If you have problems submitting this form online, you may print and mail it to:

Dr. Deborah Henken
Developmental Biology, Genetics and Teratology Branch
NICHD, National Institutes of Health
9000 Rockville Pike, Bethesda, MD 20892
Tel: 301-496-5541, Fax: 301-480-0303
E-mail: henkend@exchange.nih.gov

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