Animal Intake Processing Form Order Number:5
Fax to: 301-846-6590 Request Date:11/13/2013

Investigator Requesting (receiving) Intake

Name: Alfred Singer
Building: 10
Room: 3N113
Telephone: 301-496-5461
E-Mail: singera@exchange.nih.gov
Center Number: N/A
Shipping Method: World Courier
Shipping Account #: 315386
Shipping Payment: Not Selected
Estimated Cost:
Accepted Cost: Recipient Paid


Person Completing Form
Name: Tejas Kadakia
Telephone: 301-435-6449
E-Mail: tejas.kadakia@nih.gov


Material Transfer Agreement Information
MTA on file and required: Yes
MTA Number: MTA # 37031-14


Intake Information
NumSpeciesStrainSexColorAgeBldg./Rm.
2MiceCXCL12 FloxedMaleAgoutiBld 567 Room 112
Number of Boxes: 2
Requested Shipping Date: 11/18/2013
Shipped Date:
Transfer Confirmed with PI?: Yes


Investigator sending Shipment
Name: Sean Morrison
Alternate Info:
University/Institute: UT Southwestern/ Childrens Medical Center Research Institute
Address 1: 5323 Harry Hines Blvd.
Address 2:
City: Dallas, TX 75390
State: Texas
Zip: 75390
Country: USA
Telephone:
E-Mail: sean.morrison@utsouthwestern.edu


Contact Person (shipping facility):
Name: Kristen Correll
Telephone:
E-Mail: Kristen.Correll@UTSouthwestern.edu


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