Sirius Canine Fertility, Inc



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Date02.06.2018
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Sirius Canine Fertility, Inc

PO Box 741

Cedar Ridge, CA 95924

530-273-9123 ( phone )

530-273-9128 (Fax)

info@siriuscaninefertility.com ( email)


FROZEN CANINE SEMEN OWNER RELEASE FOR DISPOSAL

This document, when completed, signed, witnessed and dated, requests SCF to dispose of the frozen canine semen listed below. All Co-Owners of this frozen semen must sign this document in order for the semen to be destroyed.


I____________________________________________________________________

Name of present owner, coowners of frozen semen


Do hereby transfer all rights of ownership and interest in the following frozen semen to Sirius Canine Fertility, Inc. This request is for the frozen canine semen on the dog listed below to be destroyed/ disposed of:
________________________________________________ __________________________

Registered Name of Dog Registry


_______________________________ ___________________________________

Registration Number Breed


The following semen from the above dog is to be destroyed.
Date of collection:_____________________ Number of vials:___________________
Date of collection:_____________________ Number of vials:___________________
All semen from the Above Dog:__________________________________________________________________________

Signature here if you wish to destroy all of the frozen semen on the dog


I/ we do request that the specific frozen semen listed above be destroyed:
________________ ________________________________________________________

Date signature (s) of present semen owner and coowner


Printed Name of Owners/Co Owners:________________________________________________
Address:_______________________________________________________________________
Telephone:___________________________ Email:____________________________________

witness signature:_________________________________________________
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