Cooled Semen Order - Rogue Equine & Companion Animal Clinic

Todays Date?*

Agent or veterinarian - if making semen order - Information

Are you an agent, veterinarian or representative of the owner?*

If you indicate yes, please complete the following sections. Otherwise please skip to the owner section.

Agent Name

First Last

Agent Mobile Number

Agent Email Address

Who do we communicate with?

Mare Owner Name*

First Last

Owner Mailing Address (if different, otherwise leave blank)

Street Address Address Line 2 City State ZIP Code

Owner Physical Address*

Street Address Address Line 2 City State ZIP Code

Owner Mobile Phone Number*

Owner Email

Mare Name*

Mare Name

Age*

Breed (please fill in)*

Mare Registration Number*

Stallion Name

Date to RECEIVE semen*

Shipping Method*

FedEx - Standard Overnight (included in estimate)
FedEx - Standard Overnight, HOLD AT COUNTER
FedEx - Standard Overnight, SATURDAY DELIVERY
FedEx - Standard Overnight, SATURDAY DELIVERY and HOLD AT COUNTER
FedEx - Priority Overnight (additional cost and subject to area availability)
FedEx - First Overnight (additional cost and subject to area availability)
Counter to Counter - Airline, same day (additional cost and subject to airline cargo hours of operation on receiving end)
Pickup at Facility (picked up at Rogue Equine)

Airport 3 letter code - if counter to counter

SHIP-TO Physical address - Required for FedEx or Airline

Street Address Address Line 2 City State ZIP Code

Name of person receiving shipment*

First Last

Name of person responsible for payment*

First Last

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Phone

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