US Semen Shipment Form - Synbiotics Corporation

Domestic Shipment Request Form
12200 NW Ambassador Dr Ste 101
Kansas City MO 64163
(800) 228-4305 Fax: (816) 464-3521
Extent of Obligation & Limitation of Liability Waiver
Synbiotics Corporation takes great pride in successfully completing shipments domestically and
internationally for our customers. For decades we have assisted our customers in producing puppies
all around the world. In consideration of circumstances beyond our control, we require this liability
waiver be read and signed for all of our shipments.
Your business is greatly appreciated!
a) Synbiotics makes no representation or warranty that a successful whelping will result from any breeding. It
is recommended that breeders refer to their inseminating Veterinarian when deciding the straws per
insemination and make adjustments accordingly. Synbiotics is not responsible for accuracy of post thaw
data. Values listed were provided by the collecting Veterinarian at time of transfer to SBIO.
b) Synbiotics shall exercise reasonable care in storing semen and in training veterinarians to conduct
inseminations. Aside from the obligation to exercise reasonable care, Synbiotics shall not be responsible
for acts of commission or omission by veterinarians who are not employees of Synbiotics, and Synbiotics
expressly disclaims any such liability.
c) Synbiotics shall not be responsible for loss or accidental thawing of semen which results from storage tank
failure, from any act by non-employees of Synbiotics who may be retained to transport semen, or from any
acts by employees or agents of Synbiotics unless such acts constitute gross negligence, or from any other
cause beyond the reasonable control of Synbiotics. If such event occurs, Synbiotics’ sole liability will be to
return any prepaid fees related to the shipment.
d) If we are requested to use a vapor shipper other than a Synbiotics Corporation vapor shipper, Synbiotics
will not be responsible for any liability to return any prepaid fees related to the shipment.
STUD DOG OWNER
Signature:
Name
Printed:
Date:
BITCH OWNER
Signature:
Name
Printed:
Date:
SYNBIOTICS CORPORATION
Signature:
Name
Printed:
Date:
DSR0113 Page 1 of 3

Domestic Shipment Request Form
12200 NW Ambassador Dr Ste 101
Kansas City MO 64163
(800) 228-4305 Fax: (816) 464-3521
**All Shipment Request Forms Must Be Faxed At Least Two Business Days Prior to Shipment **
All shipments are sent Priority Overnight via Federal Express and require a signature upon receipt.
Charge
Shipment Preparation Fee – $94.50 per Dog in Shipment
This Fee Includes: Liquid Nitrogen, Packaging and Paperwork, Professional Service Fee, and Thaw Buffer, if
requested. 3139
The purpose of Synbiotics’ thaw buffer is to increase volume;
If your veterinarian would like thaw buffer, please mark here
Vapor Shipper Rental – $84.00 for One week
This Liquid Nitrogen charged vapor shipper preserves your frozen semen for a minimum of 7 consecutive days. This
fee is charged for the use of the shipper for those 7 days.
Any additional days will be charged a $25 per day late fee. 3141
Delivery Service Fee – Roundtrip pre-determined by Fed Ex for the following zones:
Zone 1 IA, KS, MO, NE 3153 $163.80
$84.00
Zone 2
AL, AR, CO, DE, GA, IL, IN, KY, LA, MD, MI, MN, MS, NC,
NM, OH, OK, PA, SD, SC, TN, TX, WI, WV 3154
$245.70
Zone 3 All Other States 3155 $275.10
A pre-paid FedEx return label is included for return of the vapor shipper to Synbiotics.
Additional Insurance – $2.10 per $100 Valuation Customer assumes responsibility for the shipment once
it leaves Synbiotics. Fed Ex insures the contents of the vapor shipper for $250. This insurance is included in the
freight charge. Additional purchased Insurance will cover the contents of the vapor shipper beyond the $250. 3127
Fed Ex Priority Alert – $23.10 This specialized, tightly controlled Fed Ex service provides proactive notification
to customers in the event that this critical shipment might be delayed and guarantees delivery by end of day. The only
possible exception would be due to weather. FedEx Priority Alert is recommended if the shipment arrives the day of
insemination. 3140
Saturday Deliveries – Please contact Fed Ex for Saturday Delivery Availability! Saturday service is not available
in all locations. Please check with your veterinarian to verify they are open on Saturdays. If you require Saturday
Delivery there is an additional $15.75 charge for this service. 3156
Expedited Order Fee – An additional fee is assessed for paperwork received less than two business days before
shipment date. Please be aware that these shipments are processed as time permits and may not always be possible!
Rush Fee Next Day Shipments 3151 $65.63
Urgent Rush Fee Same Day 3152 $120.75
Payment Information
Total Shipment Charges
Payment Type MasterCard Visa AMEX
Card Number
Card Holder Name
Address
Expiration Date
City State Zip
Purchaser Authorization Signature
The cardholder is financially responsible for the payment of all fees, including late return of vapor shipper, if applicable.
The vapor shipper is valued at $1365.00 and the cardholder will be charged this amount if shipper is NOT returned.
Failure to completely fill out this form may delay your shipment!
DSR0113 Page 2 of 3

Domestic Shipment Request Form
12200 NW Ambassador Dr Ste 101
Kansas City MO 64163
(800) 228-4305 Fax: (816) 464-3521
Submission Date
Requested
Delivery Date
STUD OWNER INFORMATION
Owner’s Name
Address
City
State
Zip
Code
Phone
Email for Tracking
STUD DOG INFORMATION
Call Name
Registration Name
Registration Number
Breed
No. of
Straws to Be
Shipped
Straw
Collection
Date
Stud Dog Owner
Authorization
Signature
I hereby certify that the information provided by me in this document is true and accurate to the best of my ability.
INSEMINATING VETERINARIAN/SHIPPING ADDRESS
Hospital Name
Address
Attention
City State Zip Code
Phone
Email for Tracking
BITCH OWNER INFORMATION
Owner’s Name
Address
City State Zip Code Phone
Call Name
Registration
Name
Email for Tracking
Breed
Registration
Number
Synbiotics will provide confirmation that your form was received.
Please select the method of confirmation.
(Phone, FAX, Email)
DSR0113 Page 3 of 3