Animal Intake Processing Form Order Number:7
Fax to: 301-846-6590 Request Date:3/18/2014

Investigator Requesting (receiving) Intake

Name: Nicholas Restifo
Building: 10-CRC
Room: 3-5762
Telephone: 301-496-4904
E-Mail: restifo@nih.gov
Center Number: N/A
Shipping Method: Not Selected
Shipping Account #: Not Listed
Shipping Payment: Not Selected
Estimated Cost:
Accepted Cost: PI Accepted Cost


Person Completing Form
Name: Shashank Patel
Telephone: 3019790911
E-Mail: patelsj@mail.nih.gov


Material Transfer Agreement Information
MTA on file and required: Yes
MTA Number: Material transfer has been signed with University of Pennsylvania


Intake Information
NumSpeciesStrainSexColorAgeBldg./Rm.
1MiceATR flox/-MaleAgouti
1MiceATR +/-MaleAgouti
1MiceCre-ERTMaleAgouti
1MiceATR flox/-FemaleAgouti
1MiceATR +/-FemaleAgouti
1MiceCre-ERTFemaleAgouti
Number of Boxes: 0
Requested Shipping Date:
Shipped Date:
Transfer Confirmed with PI?: No


Investigator sending Shipment
Name: Eric Brown
Alternate Info:
University/Institute: University of Pennsylvania
Address 1: 514 BRB II/III, 421 Curie Boulevard
Address 2:
City: Philadelphia,
State: PA
Zip: 19104-6160
Country: USA
Telephone: (215) 746-2805
E-Mail: brownej@upenn.edu


Contact Person (shipping facility):
Name:
Telephone:
E-Mail:


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