Form to request ES cell line derivation

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PI Date
Contact person Lab room
Phone Email
Department Cancer Center member?
PTAO Funding source NIH etc.
Male
Zygosity
Male strain # of males  submitted
Female
Zygosity
Female strain # of females submitted
Animal protocol # CCM #
Mouse room:

Brief description of the purpose of ES cell line derivation and special note to GTTF:

GTTF is capable of deriving ES cell lines from multiple wildtype and mutant strains.  To initiate this service, the investigators are required to provide 5 breeding males and 10 prepuberty females.  The male mice will be transferred back to investigators upon completion of the projects.  The derivation service includes karyotyping, sexing and alkaline phosphatase activity assessment.  Investigators will need to make separate requests for blastocyst injections in order to test the pluripotency of the established ES cell lines.

investigator's signature for agreeing to the terms

 GTTF's signature for acceptance of the project

Please fill out the form and click "Submit" button to send the request electronically to GTTF.  Click "Back" button on your web browser to print, sign and bring the form to Jordan 2223 (ext. 2-3990) to confirm the timeline of the service.  Electronic signature is not available at this time.