Primate Sales/Purchase Request Form

Fields in *red* are required.
A. Contact Information
Investigator
Name:
Institution:
E-mail:
Phone:
Fax:
Billing Address
Address:
City:
*State/Province:**
Postal Code:
Country:
Shipping Address
Address:
City:
*State/Province:**
Postal Code:
Country:
Your Veterinary - Resources Group Contact
Name:
Phone:
E-mail:
B. Will the animal(s) be used for Federally funded research?
Yes. Ongoing Research.
Please supply the following information:
Grant Number :
Title:
Principal Investigator :
Total Amount of Grant:
Agency/Institute that Awarded Grant:
Yes. New Application for Federal Funding.
Please supply the following information:
Agency :
Date :
Title:
Principal Investigator :
No. Funding for this research is from: Commercial Other
C. Animal information
Species:	Baboon Marmoset Rhesus macaque Other (Please Specify):
Sex and Quantity:	Male Female
Age:	Infant Juvenile Adult Geriatric Specific Age Range yrs
Weight Range:	kg
Naive?:	No Yes
Research Purpose:
Special Testing?:	Herpes Measles SIV SRV Viral Isolation Antibodies Other
Dates Animals Needed:	[MM/DD/YEAR]
D. Do you want this information for a quote or for a purchase?
QuotePurchase
E. If you have discussed this request with an SNPRC staff member, please provide a name.
SNPRC Staff Member Name:
Comments:

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