Application for DNA Repository

1 CHIC DNA Repository2300 E Nifong Blvd, Columbia, MO 65201-3806 Phone: (573) 442-0418; Fax: (573) for DNA Repositorylast updated 06/10/14 DNA Sample Submission AgreementI hereby donate, assign, and transfer a DNA sample of the dog named above to the CHIC DNA Repository for research purposes and warrant my authority to do so. I understand that any future use or distribution of this DNA sample will be within the sole direction and authority of the CHIC DNA Repository . I authorize the OFA to provide any researchers receiving a portion of this sample with all necessary information including pedigree and health history to make the sample useful. My intent in providing this DNA sample is to further research into canine health issues.

2 I hereby relinquish all rights to, and ownership of, the DNA _____Signature of owner/agent DateDog Call Name: _____Previous Application number (if any):Registration number: q AKC q CKCO ther registry name:Other registry #:Registered name:Sex:Color:Breed:Date of Birth (month-day-year):ID Number (if any): q Tat too q MicrochipRegistration number of sire:Registration number of dam:Owner name:Co-owner Name:Mailing address:Owner Email:City:State:Zip/postal code:Owner Phone:CANINE HEALTHUpon receipt and processing of this Application , the owner will receive a Sample Submission Kit depending on the option selected NOT SUBMIT SAMPLE WITH THIS INITIAL fill out the health survey on the back of this form with later swab or blood Submission Kit Ordero Swab Based Collection Kit $ (includes 4 cheek swabs to be submitted, collection instructions, health survey, mailing labels)o Blood Collection Kit $ (includes collection instructions, health survey, mailing labels)_____ _____ _____ _____Visa/Master Card Number Name on Card Exp Date CVV (security code)Payments can be made by check, money order ( funds drawn on a bank)

3 , cash, Visa, or Mastercard, payable to the Orthopedic Foundation for Disorders Yes Noo Distichiasiso Dry Eyeo Entropiono Juvenile Cataractso Non Healing Corneal Ulcero Retinal Dysplasiao Persistent Pupillary Membraneo Glaucomao Cherry Eyeo Other _____Ear Disorders Yes Noo Chronic ear infectiono Deafness (if yes,describe coat color/pattern) _____o Other _____Skin Disorders Yes Noo Atopic Dermatitis (allergy to inhaled substances)o Food/Medicine Allergieso Alopeciao Autoimmune Skin Diseaseo Systemic Demodectic Mangeo Sebaceous Adenitiso Seborrheao Other _____Gastrointestinal Disorders Yes Noo Pyloric Stenosiso Megaesophaguso Cleft Palateo Chronic Vomitingo Choric Colitiso Inflammatory Bowel Diseaseo Other _____ Respiratory Disorders Yes No o Congenital Tracheal Stenosis (narrow trachea)o Stenotic Nareso Elongated Soft Palateo Laryngeal Paralysiso Other _____Orthopedic Disorders Yes Noo Hip Dysplasiao Patellar Luxationo Elbow Dysplasiao Premature IVD (intervertebral disc degeneration)

4 O Vertebral Anomalieso HODo Other _____CHIC DNA Repository Health SurveyCANINE HEALTHHas this dog ever been diagnosed with any of the following health issues? For each section you answer with a yes, please fill out the rest of the section. If you answer no to any section, skip to the next Disorders Yes No o Vascular Ring (right aortic arch)o Subaortic Stenosiso Pulmonic Valve Stenosiso Persistent Ductus Arteriosuso Persistent Foramen Ovaleo Tricuspid Valve Defecto Mitral Valve Defecto Cardiomyopathyo Porto-Systemic Vascular Shunt (Liver Shunt)o Other _____Urinary Disorders Yes Noo Ectopic Uretero Urinary Crystals/Stoneso Other _____Blood/Lymph Disorders Yes Noo Autoimmune Hemolytic Anemiao Hemophilia (Type A or B)o Idiopathic Thrombocytopeniao vonWillebrand s disease (Symptomatic?)

5 Y No Other _____Endocrine Disorders Yes No o Hypothyroido Addison s disease (adrenal insufficiency)o Cushing s disease (adrenal oversecretion)o Diabeteso Other _____Reproductive Disorders Yes Noo Cryptorchid/Monorchido Abnormal Spermo Testicular Atrophyo Irregular heat cycleo Uterine Inertiao Other _____Neurologic Disorders Yes No o Epilepsyo Caudea Equina Syndromeo Degenerative Myelopathyo Other _____Cancer/Tumors Yes Noo Mast cell tumoro Lymphomao Hemangiosarcomao Testicular cancero Mammary cancero Osteosarcomao Other _____