National Institutes of Health

National Institute of Child Health and Human Development

Request for Animals

Please fill out this form and click on the "Submit" button once to submit your request. If your browser does not support forms then you can e-mail the information to Dr. Deborah Henken, Project Officer. Information is at the end of this form.

Date:

Principal/Other Investigators:

Institution:

Address:

Phone Number:

Fax Number:

Email address:

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 (Approxmiate)

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 now. Print now for your records.

Submit form to the project officer:

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