Cooled Semen Shipment Order This completed form is required by law in order for us to provide service. This information is kept secure, private and will not be shared with any 3rd party without your expressed consent. Todays Date?* MM slash DD slash YYYY Agent or veterinarian - if making semen order - InformationAre you an agent, veterinarian or representative of the owner?* Yes No If you indicate yes, please complete the following sections. Otherwise please skip to the owner section. Agent Name First Last Agent Mobile NumberAgent Email Address Who do we communicate with? Agent Owner Owner InformationMare Owner Name* First Last Owner Mailing Address (if different, otherwise leave blank) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Physical Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Owner Mobile Phone Number*Owner Email Mare InformationMare Name* Mare Name Age* Breed (please fill in)* Mare Registration Number* Shipping InformationStallion Name Stallion Name Date to RECEIVE semen* MM slash DD slash YYYY 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of person receiving shipment* First Last Name of person responsible for payment* First Last CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
