Receiving Investigator Application Form

Dear Investigator,

The information requested below is confidential and will be used to help ensure that rats are shipped to and used by organizations that have appropriate staff and housing to care for these animals.

Required information is marked with an asterisk (*). Please use "n/a" as needed.

Due to the small size of colonies maintained at the RRRC, we cannot typically accommodate requests for specific ages or weights of rats.  Animals shipped are between 3 weeks to 4 months of age.

---

Institution/Organization:
	Name:
	Type:	For ProfitNon-Profit Tax Exempt No.:
Investigator Contact Information:
	Name:	*
	Phone:	*
	Fax:
	E-mail:	*
Shipping Information for Animal Facility:
	Name/Organization:
	Address:
	City:
	State/Province:
	Zip/Postal Code:
	Country:
Billing Information:
	Institution/Organization:
	ATTN:
	Address:
	City:
	State/Province:
	Zip/Postal Code:
	Country:
	Phone #:
	Purchase Order #:
RRRC Product Use Limitations:
Any recipient of rats or othrer material from the RRRC agrees to the terms and restrictions of the RRRC Outgoing MTA. Recipient and institutional official must execute the RRRC Outgoing Material Transfer Agreement (MTA) before the request will be shipped.
Animals Requested (quantities are limited):
	Strain Requested:
	RRRC Catalog # Requested:	*
	# of Live Males:	$150/rat
	# of Live Females:	$150/rat
	Genotype Preferred (if available):
	# of Straws - Embryos: (20 Cryopreserved Embryos per straw)	$1800/straw
	# of Straws - Sperm:	$500/straw
	Cryo Resuscitation:	$2000/litter
	ES Cell Line:	$850/vial
	Other (e.g. tissue):
Attending Veterinarian or Contact Person for Animal Shipment Authorization: (Animals will not be shipped until the RRRC receives authorization for animal receipt by the Receiving Investigator's institution.)
	Name:
	Phone:
	E-mail: