Chilled Semen Shipment – Rose City Veterinary Hospital

Owner's Information

Stud Dog's Owner's Name*

First Last

Stud Dog's Owner Phone*

Type of AI (Very Important)*

Transervical
Surgical
Vaginal

Recipient Information

Recipient Name*

First Last

Recipient Address*

Street Address Address Line 2 City State ZIP Code

Recipient Phone*

Recipient Email*

I Would Like To Add Insurance To My Shipment (Check One)*

Yes
No

I understand that there is a charge of $265.00 for the collection, preparation and packaging of the semen. The price includes shipping the semen via Federal Express within the USA (priority overnight). ***** Please check availability for Saturday Delivery and First Overnight***** Additional rates apply: Saturday $25.00 First Overnight $50.00 Federal Express offers Shipping Insurance; Insurance is $1.00 per $100.00 increment over $500.00. We recommend insuring for the value of the semen. FedEx must take possession of the package for insurance to be valid.

Additional Insurance Amount

Payment Information

Name on Card*

First Last

Card Type*

Card Number*

Expiry Date*

Security Code on Back*

Billing Zip Code*

I Authorize Rose City Veterinary Hospital To Charge My Credit Card In The Amount Of: (Please Add $265.00 + Additional Fees Such As Insurance Or Sat Delivery)*

Electronic Signature (type name)*

By submitting this document to Rose City Veterinary Hospital. YOU AGREE TO PAY ABOVE TOTAL AMOUNT ACCORDING TO CARD ISSUER AGREEMENT (MERCHANT AGREEMENT IF CREDIT VOUCHER

Chilled Semen Shipment - Domestic

Owner's Information

Recipient Information

Payment Information

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