Animal Intake Processing Form Order Number:3
Fax to: 301-846-6590 Request Date:8/20/2013

Investigator Requesting (receiving) Intake

Name: Andre Nussenzweig
Building: 37
Room: 1106
Telephone: 301-435-6425
E-Mail: nussenza@exchange.nih.gov
Center Number: N/A
Shipping Method: World Courier
Shipping Account #: Not Listed
Shipping Payment: Prepaid
Estimated Cost:
Accepted Cost: Recipient Paid


Person Completing Form
Name: Jacqueline Barlow
Telephone: 301-496-4669
E-Mail: barlowjh@mail.nih.gov


Material Transfer Agreement Information
MTA on file and required: Yes
MTA Number: NCI MTA#36484-13


Intake Information
NumSpeciesStrainSexColorAgeBldg./Rm.
3MiceRnaseH2b f/f Cd19 creMaleBrown6 weeks
3MiceRnaseH2b f/f Cd19 creFemaleBrown6 weeks
Number of Boxes: 3
Requested Shipping Date:
Shipped Date:
Transfer Confirmed with PI?: Yes


Investigator sending Shipment
Name: Axel Roers
Alternate Info:
University/Institute: University of Technology Dresden
Address 1: Medical Faculty
Address 2: Carl Gustav Carus
City: Dresden
State:
Zip: 01307
Country: Germany
Telephone: +49(0)351 458 6500
E-Mail: Axel.Roers@tu-dresden.de


Contact Person (shipping facility):
Name: Bjoern Hiller
Telephone: +49-351-4586502/-6503
E-Mail: Bjoern.Hiller@mailbox.tu-dresden.de


Attending Veterinarian (shipping facility):
Name:
Telephone:
Fax:
E-Mail:


Shipper's Statement
Animals have NOT been inoculated with live microorganisms.
Animals have NOT been administered tumor/cells.


Notes and Comments

_________________________________________ _________________________________________
Shipper/Investigator Signature Facility Manager/Consigner Signature