Form to request ES cell karyotyping

Before filling out this form, please click "Print this Page" button at the bottom of this page to set this form to a printer friendly version.

PI Date
Contact person Lab room
Phone Email
Department Cancer Center Member?
PTAO Funding source NIH etc.
Label of ES cell clone Targeted gene
Name of ES cell line R1, CJ7, W4, RW4 etc. Source of line GTTF, outside institution, Bay Genomics
# of vials submitted # of cells per vial
Mycoplasma test
 Unknown
MAP test
 Unknown

Brief description of the targeting experiment and special note to GTTF:

If one vial is submitted for ES cell karyotyping, GTTF will grow the cells and freeze 4 vials (ES cell expansion charge applies).  GTTF counts at least 40 chromosome spreads and reports the result via an email.

investigator's signature for agreeing the terms

GTTF's signature for acceptance of the project

Please 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.