GENERAL SUBMISSION FORM

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1 GENERAL SUBMISSION FORM Explanatory notes: PART A Customer information (Owner, Breeder or Vet clinic). Please fill this part just once for an order; it doesn't matter on number of animals or analyses. PART B Animal information. Please fill this part for all of animal in one order. (For example, if you have 3 animals you need to fill PART 3 three times (page no. 1 and 5). Customer verifies the data with the signature. PART C This part contains all analyses that are possible to order by Slovgen Laboratory. Please type required analyses from PART C in this form to TABLE 1. (Do not print / do not send) TABLE 1 Required analyses are filled by customer from PART C. TABLE 2 Will be filled by laboratory. PART A: CUSTOMER INFORMATION Owner: Name: Address (Street, ZIP code, City, Country): Vet clinic: (Confirmation of the correctness of the biological material and animal data): Name of vet: Address: Phone number: Reg. No. Vet: VAT Invoice to: vet clinic owner /breeder Results by: mail Payment method: bank transfer PayPal Results to: vet clinic owner PART B: ANIMAL INFROMATION #required information Sample:# blood (EDTA) buccal swab Date of collecting sample:# Microchip No.: Tattoo No.: 1

2 PART B: ANIMAL REFERENCES #required information Sample:# blood (EDTA) buccal swab Date of collecting sample:# Microchip No.: Tattoo No. : PART B: ANIMAL REFERENCES #required information Sample:# blood (EDTA) buccal swab Microchip No.: Date of collecting sample:# Tattoo No.: 2

3 PART C: Choose required analyses from table bellow: (do not print / do not send) Canine (results are usually in 5 working days, * analyses usually took 10-15working days) CEA-EVG CEA-SG CKCSID* CMO CMR1 CN*- GCS CNM CSNB CYS Fa VII DM- DogTest partner lab DM-SG partner lab DM - BSP exon 1 Collie eye anomaly (by cooperating lab EVG Maribor) Collie eye anomaly (partner lab under Slovgen supervision) dry eye curly coat syndrome for Cavalier King Charles Spaniel - congenital keratoconjuctivitis sicca and ichthyosiform dermatosis Craniomandibular osteopathy - for terriers Canine multifocal retinopathy type 1 in Great Pyrenees, English Mastiffs, Bullmastiffs, Cane Corso, Dogue de Bordeaux, English Bulldog, American Bulldog, Pero se Presa Canario and Australian shepherds Cyclic Neutropenia (CN) - GREY COLLIE SYNDROME - grey collie, smooth and rough collie (Centronuclear Myopathy)/ HMLR (Hereditary myopathy of Labrador retrievers) Congenital Stationary Night Blindness for Briard Cystinuria for Newfoundland dogs and Landseer Factor VII deficiency - Deficit faktoru VII (Airedale Terrier, Alaskan Klee Kai (Miniature Alaskan Husky), Giant Schnautzer and Scottish Deerhound) Degenerative myelopathy (by cooperating lab DogTest lab) 65 euro per dog Degenerative myelopathy (partner lab under Slovgen supervision) - 50 euro per dog Degenerative myelopathy for Bernese mountain dog DMS DWARF DWARF-LABR EFS FN FUCA GG GR-PRA1* GR-PRA2* HC/HSF4* HUU* ICT-A: IGS JLPP* JME JRD L-2-HGA* MH* Dermatomyositis Pan2/MAP3K7CL/DLA-DRB1*002:01 for collies and shelties dwarfism (pituary nanism) German shepherds, Saarloos Wolfdogs and Czechoslovakian Wolfdogs SD2 - skeletal dysplasia 2 for Labrador (Episodic Falling Syndrome) for Cavalier King Charles Spaniel Familiar Nephropathy English Cocker Spaniels Fucosidosis in English Springer Spaniels Goniodysgenesis and glaucoma in Border Collies for Golden retriever for Golden retriever hereditary cataract Australian shepherd, Staffordshire Bull Terrier a Boston Terrier Hyperuricosuria Congenital Ichthyosis*for Golden retriever Imerslund-Gräsbeck syndrom (Border collie) Juvenile Laryngeal Paralysis & Polyneuropathy (JLPP) - Rottweiler, Black Russian Terriers JME - Juvenile Myoclonic Epilepsy - Rhodesian Ridgeback Juvenile renal dysplasia - several breeds L-2-HGA - L-2-hydroxyglutaric aciduria in Staffordshire bull terriers Malignant Hyperthermia, all dogs 3

4 MDR1 MLS NAR NBT NCCD NCL5 NCL NCL6* multidrug resistance gene direct detection of nt230(del4) Musladin-Leuke Syndrom (Beagle) Narcolepsy for Labrador Retriever Bob Tail/ Short Tail N. can Neospora caninum NEWS NCCD: Neonatal cerebellar cortical degeneration - cerebellar abiotrophy Beagle (neuronal ceroid lipofuscinosis for Border collie (neuronal ceroid lipofuscinosis for Tibetan Terriers (neuronal ceroid lipofuscinosis for Australian Shepherd Neonatal encephalopathy with seizures Standard Poodle OCA-2 OCA-2 - Spitz - Oculocutaneous albinism type 2 OCA-4 Bull OCA-4 Dob pap-pra1 PK-BEAG PK-LABR PK-MOPS PK-WHWT PLL PRA1-GR* PRA2-GR* PRA-cord1 PRA-cord2 PRA-prcd PRA-rcd2 PRA-rcd3 PRA-rcd4* PRA-shet Raine Syndrome (DH) SDCA1 SDCA2 SN TNS OCA - Oculocutaneous albinism Bullmastiff (c.1287delc in gene SLC45A2) OCA - Oculocutaneous albinism Doberman (SLC45A2, 4081bp del) progressive retinal atrophy - for Pappilons, Phalens Deficiency of pyruvate kinase for Beagle Deficiency of pyruvate kinase for Labrador retriever Deficiency of pyruvate kinase for Pug (Mops) Deficiency of pyruvate kinase for Cairn Terrier and West Highland White Terrier Primary lens luxation Progressive retinal atrophy for Golden retriever = GR-PRA1* Progressive retinal atrophy for Golden retriever = GR-PRA2* Progressive retinal atrophy for Standard wire-haired dachshunds, miniature long-haired dachshunds, English springer spaniels and pit bull terriers Progressive retinal atrophy for standard wire-haired dachshunds Progressive retinal atrophy for several breeds Progressive retinal atrophy for Collie Progressive retinal atrophy for Cardigan Welsh Corgi Progressive retinal atrophy for Terriers, Setters etc. Progressive retinal atrophy for Sheltie (CNGA1) Raine syndrome - Dental Hypomineralization for Border Collie SDCA1 -Spongy cerebellar degeneration with cerebellar ataxia (Belgian shepherds malinois) SDCA2 -Spongy cerebellar degeneration with cerebellar ataxia (Belgian shepherds malinois) Sensory neuropathy for Border Collie (Trapped Neutrophil Syndrome for Border collie) T. gondii Toxoplasma gondii VDEG Van den Ende-Gupta syndrome in Wire Fox Terrier von Willebrand disease for several breed Basethound, Bernese mountain dog, Coton de Tulear, Dachshund (standard, mini), Doberman pinscher, Drentsche Patrijschond, German vwdi Shepherd, Golden retriever, Goldendoodle, Keeshound, Kerry blue terrier, Labradoodle, Manchester terrier, Miniature Schnauzer, Papillion, Poodle, Rotttweiler, Stabyhoun, Welsh 4

5 Corgi Pembroke vwdii vwdiii von Willebrand disease for German Shorthaired Pointers, German Wirehaired Pointers and Collies von Willebrand disease for Shetland Sheepdog DOG DNA PROFILING/PARENTAGE: DNA profile STR-21 loci + amelogenin (ISAG 2006), DNA profile including parentage test/confirmation COAT COLOR AND QUALITY: Hairlessness FGF5 Fluffy gene, long or short hair KRT71 Curly coat Locus A (coat colour ay >aw> at> a) Locus B Locus BE* Locus D Locus E Locus K Locus EM Locus M - Merle Locus S (spotting), white factor RSPO2/IC improper coat for Chinese Crested, Peruvian Inca Orchid and Mexican Xoloitzcuintle brown for Australian Shepherd -melanistic mask, merle/cryptic merle Feline: 1) Analysis 2) Description PKD Polycystic Kidney Disease (for cats) BIRD: 1) Analysis 2) Description Sex Bird sexing PBFD APV Ch. psittaci Psittacine Beak and Feather Disease Avian Polyoma Virus Chlamydophila psittaci 5

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