VGL
Veterinary Genetics Laboratory
HORSE MITOCHONDRIAL DNA SUBMISSION FORM
Telephone (530) 752-2211
DHL/FedEx/UPS Address
Veterinary Genetics Laboratory
Postal Address
Veterinary Genetics Laboratory
FAX (530) 752-3556
Web-site www.vgl.ucdavis.edu
University of California, Davis
Old Davis Road
Davis, CA 95616-8744
PO Box 1102
Davis, CA 95617-1102
(PLEASE PRINT LEGIBLY OR TYPE)
Owner/Agent Name: ____________________________________________________________________
Purpose: To determine maternal lines
Address: _____________________________________________________________________________
City: _______________________________________________ State: ________ Zip: _______________
Sample type:
Phone (include area code): ______________________________________________________________
Blood (preferred) - 5-8 cc of whole blood in a lavender (EDTA) top tube
FAX (include area code): ________________________________________________________________
Hair - 20 - 30 pulled hairs from the tail or mane placed in an envelope
E-mail address for results: _______________________________________________________________
Results will EITHER be (1) mailed and e-mailed; OR (2) mailed and faxed to the above.
I hereby certify that the animal described below by name and number is the animal from which the sample was taken.
Person taking sample:
Print name
Signature
Date sample taken
ANIMAL SAMPLED
Registered Name of Animal
Registration #
Only one animal per form
PARENTS OF ANIMAL SAMPLED
Date
of
Birth
Sex
Color
Sire
and
Dam
Male
S
Female
D
Name of Animal
Color
Registration #
Instructions:
1. Blood - 5 - 8 cc of whole blood in a lavender top tube (EDTA). Label tube with animal’s name or identification that matches form.
2. Hair - 20 - 30 pulled hairs placed in an envelope. Label envelope with animal’s name or identification that matches form.
3. Payment in the amount of $75 per animal may be made by check or money order payable to U.C. Regents or by American Expres s,
Discover, MasterCard or VISA.
4. Non-U.S. checks must have “U.S. Dollars” or “USD” imprinted by a bank.
5. Send package via any two-day or next-day service to address listed above.
6. Results will not be sent until payment is received.
Results:
1. One copy will be mailed to the address in upper left corner.
2. Results will also be e-mailed or faxed if information is provided in the upper left hand corner.
3. All results are confidential. The Veterinary Genetics Laboratory will not provide results by phone and the results will only be
released to person listed in upper left hand corner.
Copyright © 2012 The Regents of the University of California. All Rights Reserved.
VGL OFFICE USE ONLY
Check #
Amount
Date
Original records will be maintained on permanent file at UC Davis, Veterinary Genetics Laboratory
mtDNAForm
Revised 12/21/12
Credit Card Authorization Form
VGL Office Use
VGL Case #s: ____________________________
Amt. Charged: ___________________________
Date Charged: ___________________________
Credit Card Information
Print customer name as it appears on card:
Expiration Date:
Account Number:
CVV Code:
Daytime Phone Number:
Card Type*:
Signature of Cardholder:
Total amount authorized to be charged:
* Accepted credit cards: American Express, Discover, MasterCard, and VISA
Client’s name as it appears on sample submission form:
Credit Card Authorization Form
Revised 3/23/2012
Copyright © 2012 The Regents of the University of California. All Rights Reserved.