Animal Intake Processing Form Order Number:4
Fax to: 301-846-6590 Request Date:10/22/2013

Investigator Requesting (receiving) Intake

Name: andre nussenzweig
Building: 37
Room: 1106
Telephone: 304-435-6425
E-Mail: nussenza@exchange.nih.gov
Center Number: N/A
Shipping Method: World Courier
Shipping Account #: 201315403126
Shipping Payment: Not Selected
Estimated Cost:
Accepted Cost: Not Selected


Person Completing Form
Name: amanda day
Telephone: 301-443-3071
E-Mail: dayamand@mail.nih.gov


Material Transfer Agreement Information
MTA on file and required: Yes
MTA Number: MTA is pending signatures


Intake Information
NumSpeciesStrainSexColorAgeBldg./Rm.
2Micepu.1MaleAgouti
2Micepu.1FemaleAgouti
Number of Boxes: 2
Requested Shipping Date:
Shipped Date:
Transfer Confirmed with PI?: Yes


Investigator sending Shipment
Name: ellen rothenberg
Alternate Info:
University/Institute: Californial Institute of technology
Address 1: 1200 E. California Blvd.
Address 2:
City: Pasadena
State: CA
Zip: 91125
Country:
Telephone: 626-395-4992
E-Mail: evroth@caltech.edu


Contact Person (shipping facility):
Name: janet baer
Telephone: 626-395-3948
E-Mail: jbaer@caltech.edu


Attending Veterinarian (shipping facility):
Name: janet baer
Telephone: 626-395-3948
Fax: 626-564-0346
E-Mail: jbaer@caltech.edu


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