Animal Purchase Request Form

FACULTY NAME: ______________________________________________

DEPARTMENT: ____________________________

TELEPHONE EXT: ____________________EMAIL:_______________________

IACUC APPROVED PROTOCOL NUMBER: ____________________________

DATE OF REQUEST: ____________________________

DATE DELIVERY DESIRED: ____________________________

DELIVERY LOCATION: _______________________________________________

PREFERRED VENDOR: ______________________________________________

VENDOR ADDRESS: _____________________________________

VENDOR TELEPHONE: __________________  EMAIL: ______________________

SPECIES/STRAIN: _____________________ QUANTITY: _______ SEX: _______

WEIGHT RANGE: __________ AND APPROXIMATE AGE: __________

UNIT PRICE: __________ EXTENDED TO ORDER: _________

FOUNDATION ACCOUNT MANAGER: (If applicable) ________________________

PERSON TO NOTIFY UPON RECEIPT: ___________________________________

PERSON TO NOTIFY UPON ARRIVAL IN CASE OF ANIMAL HEALTH EMERGENCY (These people must be named on the approved protocol):

____________________________  PHONE #:____________________________

ADDITIONAL COMMENTS: (State any special needs the animals may have upon arrival)

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