Canine Sample Submission Form

ADVERTISEMENT

Sample #:____________ Date:_________________
FOR OFFICE USE ONLY
1336 Timberlane Road Tallahassee FL 32312-1766
Account # _________________ Date: ____________
Canine Sample Submission Form
Name:____________________________________ Business Name:_________________________________________
Address: __________________________________________________________________________________________
City: ___________________________________ State: ______ Zip Code: ___________ Country:_______________
Phone #: ________________________________ E-mail: _________________________________________________
Sample Information
_____________________________________________________________Registration #: ___________________
Name:
Breed: ____________________________________________________________________________________________
Gender: ______________________________ Coat Color __________________________________________________
Date of Birth: __________________________ Coat Length (long, medium, short)______________________________
Parents of Dog
*not required*
Sire’s Name: _______________________________________________________________________________________
Registration: ________________ Breed: ________________________________ Color: ________________________
Dam’s Name: ______________________________________________________________________________________
Registration: ________________ Breed: ________________________________ Color: __________________________
Test For Coat Color
Test For Genetic Disorders
 A Locus - A
y
(Sable/Fawn)
 ARVC
 GR-PRA1
 NCL 
 A Locus - A
t
(Tricolor/Tan Points)
 CEA
 GR-PRA2
 NEwS
 A Locus - a (Solid Black)
 (CD)
 HC
 OI
Cone Degeneration
Complete A Locus Profile - $75
 CLAD
 JHC
 PFK
 B Locus - b (Chocolate/Red)
 CMR1
 HGA
 PH
 D Locus - d (Dilute Blue/Lilac)
 E Locus - e (Black/Yellow)
 CMR2
 HNPK
 PKD
m
 E Locus - E
(Mask)
 IGS
 HUU
 PLL
 H Locus - (Harlequin)
 (CN)
 ICT/ICH
 POAG
Gray Collie Syndrome
B
 K Locus - K
(Dominant Black)
 CNM
 MD
 PRA-Cord1
 M Locus - (Merle)
 Cystinuria
 MDR1
 PRA-Dominant
 S Locus - S (Piedbald, Parti) 
 DM
 MH
 PRA-rcd1
Complete Color Profile - $130
*does not include Merle or Harlequin
 EIC
 MLS
 PRA-rcd3
 Factor VII
 NA
 TNS
Test For Coat Type
 Hair Curl
 Fucosidosis
 NCCD
 VWDI
 Hair Furnishings
Combination Panels
 Hair Length
 Bobtail Gene
Boxer
Australian Shepherd
English Springer Spaniel
Goldendoodle
Collie
Golden Retriever
Pembroke Welsh Corgi
Border Collie
DNA Profile/Parentage
Beagle
Labrador Retriever
Coton de Tulear
Shetland Sheepdog
 ISAG DNA profile
Poodle
French Bulldog
Staffordshire Bull Terrier
English Bulldog
 Parent Verification
 Check #___________ Credit Card PayPal
Payment
Amount: _____________
paypal@animalgenetics.us
Test results and invoice are sent via email as PDF. Check here for a copy of results by US Mail 
Credit Card Information
Print name on card:
Account #:
Exp. Date:
Signature of cardholder:
Billing zip code (postal code):
3 or 4 digit security code #:
By submitting this form, the customer understands that Animal Genetics Inc. shall in no way be liable for any incidental or consequential damages
of any kind. Animal Genetics Inc. is not responsible for the origin/source of samples submitted by the individual customer.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Miscellaneous
Go