University of Connecticut Health Center



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Center for Mouse Genome Modification

Service Request Form

Date received      

PI Name       Phone     

Contact Person      Email     

Person/Department to whom billing should be directed:     

Purchase Order Number or FOAPAL:     

ACC#, Protocol Title     

Strain of mice: CD1 C57BL/6 FVB 129 Other

Name of mouse line:      

Specific genomic modification of the animal (transgenic, KI, KO, etc.)      

Quote Number:      _____________________________

Primary reference describing generation of this mouse line:

     

Complete page 2 for specific service request

Please look at our payment policy found on our website.

Signature of Principal Investigator      Date     

Please complete this form and return it to:

Dr. Siu-Pok Yee

Center for Mouse Genome Modification

University of Connecticut Health Center

Room EB010, MC 3001

263 Farmington Avenue, Farmington, CT 06030

Phone: 860-679-3726, Fax: 860-679-1846

Email:gttf@uchc.edu

Note: A purchase order (UConn Storrs or external) or FOAPAL (UConn Health) must accompany request.

For Rederivation/Cryopreservation/IVF/Embryo transfer:

Genotype: Homozygote Heterozygote

Number of stud males:       Age      

If the mice are maintained as homozygote, number of donor females:       Age      

Name and phone number of person providing daily care and management of these animals at point of origin:     

Institution where these animals originated:

     

For Generation of Genetically Modified Mice by CRISPR or ES Cell Technology:

ID of the gene of interest (such as MGI number, gene ID or Genebank accession number):      

Specific genomic modification of animal (point mutation(s), epitope tag, global knock-out, global knock-in, conditional knock-out, conditional knock-in, etc.):      

Explanation of the construct purpose:      

For Microinjection of DNA:

Total Amount of DNA      μg (minimum60 μg) Concentration      μg /μl

Size of construct.      kb Size of insert      kb

(Please attach a map of the construct)

Restriction enzyme(s) used to isolate the insert:_     _________

(Attach a gel photo indicating the band of interest)

Phenotype expected:      

Is the expression of the transgene embryonic lethal?      

Explanation of the construct purpose:      

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