Australian BioResources
SPERM CRYOPRESERVATION REQUEST FORM
All fields in this form must be completed, indicate N/A if not applicable
Please email this form to k.taylor@garvan.org.au
1. PERSONAL INFORMATION
Date of Request
Owner
Principal Investigator
Contact Name
Email Address
Phone Number
AEC Approval #
IBC Approval #
2. SUPPLIERS INFORMATION
Name of Facility
Contact Name
Email Address
Phone Number
Does an MTA cover this line?
Have you checked if freezing is allowed
under the MTA
3. STRAIN INFORMATION
Strain Name
Background Strain
Animal ID’s
Recommended for successful archival of
lines
4 fertile males
Ideally proven breeders, 10-16 weeks old
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Australian BioResources
4. FREEZING INSTRUCTIONS
Thaw sperm, IVF and culture embryos to blastocyst.
Desired validation method
Thaw, IVF, transfer embryos into recipient mice for
development to live pups.
(Costs of respective options listed on page 2)
Genotyping of recovered pups (if
applicable)
Tissue sample processed at ABR ad genotyped at ACRF
(additional charges apply)
Tissue collected and sent to owner (please specify required
tissue)
Please note: After weaning, housing costs of recovered pups are the
responsibility of the owner.
Costs
Cost of freezing, with validation by culture
$725.09 (partners)
$833.85 (externals)
Cost of freezing, with validation by live pup birth
$1417.94 (partners)
$1630.64 (externals)
Annual cost of holding frozen sperm
$25 per line
($20 per line if more than 4 lines are stored)
I agree to pay the costs as indicated above.
Name:
___________________________________________
Signature:
___________________________________________
Date:
______________________
Purchase Order No. (if applicable) ___________________________
Please direct any queries to Kevin Taylor (k.taylor@garvan.org.au).
Tel: (02) 9295 8596
Fax: (02) 9295 8566
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Australian BioResources
For ABR use only:
Programme / Schedule:
Projected Program Start Date: ____________________
Completion Date: ______________________________
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