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.