Cryos International – Denmark ApS
Vesterbro Torv 1-3, 5. | 8000 Aarhus C | Denmark | Website: dk.cryosinternational.com
E-mail: [email protected] | Tel.: +45 8676 0699 | Fax: +45 8676 0685
Delivery Statement
(All not dotted lines must be filled in)
ID number: __ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ (only if own sperm)
Deposit number: _ _ _ _ _ _
Donor number (only if reserved donor sperm): _ _ _ _ _ _
Name:__________________________________________________________________
Address:________________________________________________________________
Zip code: ________ City:___________________________________________________
State: _____________________________Country: _______________________________
Name of spouse (ID number): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _
By my signature I confirm that the sperm (own or reserved from Cryos donor) deposited at Cryos
shall be delivered to:
Name: __________________________________________________________________
Address:_________________________________________________________________
Address:_________________________________________________________________
Zip code:_________ City:____________________________________________________
State: _____________________________Country: _______________________________
Please indicate number of straws, quality, etc. to be delivered. If nothing is indicated, I hereby
authorise Cryos to choose for me:
_____________________________________________________________________
Please indicate shipping date: ______________
Please select shipping method (pick up/dry ice/nitrogen tank) _______________________
I will pay any costs related to the handling and shipment according to this Delivery Statement.
Shipping prices are available on our website.
Date: _______________________ Signature: __________________________________
* * * Copy of valid picture ID must be attached (passport, driving license, etc.) * * *
Control/date: _______________
(to be filled out by Cryos)
41.02.01-01.SS Delivery Statement
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