1 DELTAMUNE Sample Submission Waybill Account for DAFF OBC Farm Reg/Sender Ref No: Submission Date: Details of Sender Title: Lab Number: Delivery Address: Initials: DELTAMUNE Oudtshoorn Laboratory Surname: BOKOMO Premises Postal Address: 15 – 17 Rademeyer Street OUDTSHOORN Tel: 044 272 7159 Tel: Fax: Cell: E-Mail: Fax: 086 759 4855 Details of Farm Municipal Registered Farm Name: GPS Coordinates DEGE: (Degrees East) State Veterinarian Title: Municipal Registered Farm Number: DEGS: (Degrees South) Owner of Animals Initials: Title: Surname: Surname: Postal Address: Physical Address: Province: Province: Tel: Signature: Fax: Tel: Initials: Fax: Cell: PTO 248 Jean Avenue, Lyttelton, Centurion • PO Box 14167, Lyttelton, 0140, South Africa • Tel: +27(0)861 133 582 • Fax: +27(0)861 133 582 Email: [email protected] • Website: www.deltamune.co.za Directors: Mr SA Bentz • Dr EE de Bruyn • Mr RJ Franklin • Dr SP Swanepoel • Dr JC Swart (CEO) Registered name: DELTAMUNE (PTY) LTD • 1994/005981/07 DELTAMUNE Sample Submission Waybill Account for DAFF Animals Purpose of testing - Please tick appropriate box Species: OSTRICH Pre-slaughter .X. Total census of Ostriches on farm: Pre-movement .X. Age: Refer to back of page with bird numbers 6 monthly testing .X. Type of Specimens Follow-up on positive test results Serum: No of samples .X. Tracheal Swabs: No of swab pools Date of first positive result: ................................. Other samples: e.g. Organs/Cloacal swabs/Faeces Specify other samples: ..................................................... Sampling date: .................................................................. Detailed explanation for purpose of testing including relevant farm history For office use only DAFF: Approved/Not Approved Stamp and Signature: 2 3