1. All assisted reproduction techniques including but not limited to the transfer of embryos or oocytes must be performed within the State of New Mexico unless the service is not readily available in the state. OOCYTES may be done in other states if the out-of-state ICSI requirements are followed. The mare would be required to be enrolled in the Export Broodmare Program by October 1st of the year she was taken out of New Mexico, as would any recipient mares.

Name of Broodmare *

Stallion bred to: *

Date ICSI procedure performed *

Was an Embryo Transfer(s) performed? *

Yes
Yes & embryo(s) were frozen
No – Embryo(s) frozen for later implantation

Number of Frozen Embryos: *

Name of out of state farm/location mares were taken to: *

City *

State *

Zip *

Phone *

Owner(s) of Broodmare *

City (copy) *

State *

Zip *

Phone *

I CONFIRM THAT THE INFORMATION PROVIDED IN THIS FORM IS TRUE, COMPLETE, AND ACCURATE *

First

Last

Date Submitted *

Out Of State ICSI Questionaire

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