Principal Investigator

Name:

Ext:

E-mail:

Is PI a Greenebaum Cancer Center member?
(If so, subsidies may apply; please consult facility director.)

Laboratory Contact

Name:

Ext:

E-mail:

Department

Account To Be Charged: (Half the cost of injection will be charged when mice are ordered; remainder will be charged upon completion of injections.)

ARF# and Expiration Date: (Please deliver the protocol approval letter in person or by intra-departmental mail.)

Targeted Gene and Name of Construct:

If electroporation was not done by UM-SOM Transgenic Facility:

ES Cell Line used in transfection:

Source of ES Cell Line:

Passage Number of Cell Line when electroporated:

ES Cell Clones to be injected:

Passage Number of Clones to be injected:

Results of karyotype and mycoplasma tests:

The Facility requires 2 frozen vials of each clone to be injected.

Please give a description of the project as it pertains to chimeric mice. Be sure to include possible phenotypes and/or problems (i.e. embryonic lethality) that might arise from this construct.

Indicate how chimeric pups will be analyzed--breeding plans, analysis of embryos, etc.

Please remember that supporting materials should be delivered in person or by intra-departmental mail.