Loyola University Transgenic Core Facility

Loyola University Transgenic Core Facility & Custom Surgical Services
Section of Comparative Medicine
2160 S. First Avenue
Building 101, Rm.0745
TEL: (708)216-8316
FAX: (708)216-5934

ES CELL/BLASTOCYST INJECTION REQUEST FORM

Please answer each line of the request form. If you are unable to give a specific answer, type in "no info" in the space provided.

Investigator:	Department:
Contact Name:	Telephone Number:
Source of Funding	Account Number:
IACUC Number:	Approval Date:
Business Administrator:	Telephone Number:
ES Cell Line:	Passage Number:
Concentration:	Amount:

Yes No Has this cell line been tested for chimerism prior to recombination?
If no, please explain below:
Please submit the following information: 1. Print this request form with signature below. 2. A brief description of your project and its aim. 3. A schematic diagram of the recombination strategy and a photo of the recombination detection status. 4. Copies of the approval letter from the IACUC committee.
Investigator's signature: __________________________________ Date: __________________ Received by: ________________________ Date: __________________