PURCHASER __________________________________________________________________

RECEIVED BY ____________________________________________________________________________________________
                          (Signer agrees to return tank via Fed Ex within 24 hours)

AT ______________________________________________________________________________________________________
                            (Clinic, Address)

# DOSES/straws ___________ of STALLION ________________________________________________

# DOSES/straws ___________ of STALLION ________________________________________________

# DOSES/straws ___________ of STALLION _________________________________________________

# DOSES/straws ___________ of STALLION __________________________________________________

# DOSES/straws ___________ of STALLION ____________________________________________________

# DOSES/straws ___________ of STALLION ___________________________________________________

SIGNATURE ____________________________________________________________________    DATE  ___________________