Transgenic Research Center In the Cancer Center

Preclinical Oncology Service Request Form

Which service?

Contact Data:

Date: Requester Name:
Dept: PI:
PI Email: Requester Position:
E-mail: Tel:
Fax: Lab Tel:
Lab location: Cell:

Billing Account Information:

Project#  (eg, 1234567)
Task# (eg, 100)
Award (rg, ACAEH)

NCI Funded? 

Name and email of the person who has authorization to the account: 

A-PLAC protocol #:
Animal Housing Location: 
Cell line name and origin of species:

Strain of mice/rat: Injection route:
Injection medium: Injection volume (µL):
Cell number for injection: Test compound:
Test device: Delivery solvent:

Please provide information on whether the cell line has been genomically modified, if so, what is the modification method, e.g. using lentivirus.

Project summary and description (if possible, include number of groups and number of animals in each group)


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