Boarding Form – Rose City Veterinary Hospital

Complete for Chilled Semen Shipment within the United States.

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

Owner's Information