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Direct Animal Import for 567 Quarantine Request

This form is used to receive the shipment of animals at Frederick National Laboratory (Bldg 567) from locations both within the United States and overseas. This form should be submitted at least five (5) days prior to the requested receipt date. Any questions, contact Rhonda Anderson at x301-846-1431.

 
Investigator Requesting (receiving) shipment:
Name:
First Name:  
Last Name:  
Location:
Building:  
Room Number:    
Telephone #:  
E-Mail:   
Center number:
Shipping:
Method:
Account #:  
Payment:
Estimated Cost:
Accepted Cost:

Person completing this form:
Name:
First Name:  
Last Name:  
Telephone #:  
E-Mail:   

Material Transfer Agreement Information:
Is a Material Transfer Agreement (MTA) required and on file for this shipment? No
Yes
If Yes, please include the MTA Number.  If No, please explain:
 
 

Shipment Information:
Number Species Strain Sex Color Age(s) Bldg./Rm.
 
Number of Boxes:    
Requested Shipping Date:    
Shipped Date:      
Transfer Confirmed with PI?

Investigator sending shipment:
Name:
First Name:  
Last Name:  
Alternate Info: (i.e. Project #, etc.)
University/Institute:
Shipping Address:
Address 1:
Address 2:
City:
State:
Zip Code:  
Country:
Telephone number:  
E-Mail:  

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

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

Shipper's Statement:
Please answer either Yes or No to each group of statements below:
Microorganism statement:
No, the animals have not been inoculated with microorganisms. 
Yes, the animals have been inoculated with live  microorganisms that are not known to be infectious to man or other animals except under experimental conditions.
Tumor/Cells Statement:
No, the animals have not been administered tumor/cells.
  Yes, the animals have been administered  tumor/cells.

Fstro
Notes and Comments:
Please indicate any special requests or concerns in the space below.
Is request ready to be submitted? Yes No