COOLED SEMEN ORDER
Date: _________________ Time:_______________ Time Received
________________(office use)
Name of Client:
__________________________________________________________________
Phone # Home:_________________ Work:__________________ Fax:_____________________
Address:________________________________________________________________________
City, State/Province: ________________________________ Postal
Code/Zip:_______________
Shipping Address/Instructions:
_____________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Payment: Check__________ Cash_________ Money Order________ Rec. By
____________
Credit Card: Mastercard _____________ Visa ____________
Name of Cardholder: ____________________________________________________________
Credit Card# _______________________________________________ Exp.:
______________
I Authorize Countryside Farms to use my Credit Card listed above for:
| Breeding Fee | $____________________ |
| Booking Fee | $____________________ |
| Laboratory & Handling | $____________________ |
| Bioflite container | $____________________ |
| Rental of Equitainer | $____________________ |
| Fedex Return Equitainer | $____________________ |
| Others (specify) | $____________________ |
| ____________________ | $____________________ |
| Total: | $____________________ |
Signature of Cardholder ________________________________________________________
* All semen must be ordered by 10:00 pm (M.S.T.) before scheduled collection day. Collection days are Monday through Friday.
*The Above charges and Stallion Service contract must be paid in full prior to shipment.
*PLEASE FAX YOUR ORDER TO (403)885-4618. RECEPTION OF FAXES IS VERIFIED.
Name of Mare:
_________________________________________________________________
Ultrasound heat evaluation:
_______________________________________________________
____________________________ Date: ______________________ Time:_________________
Date Semen Needed ___________________________________(two doses/container)
Countryside Farms (Division of Countryside
Enterprises Ltd.)
RR#4, Lacombe, AB, T0C 1S0 (403)885-2356