P.O. Box 177, Warner, NH 03278 Phone (603) 456-2350 FAX (603) 456-2286 www.vetmed.ucdavis.edu/gdc/gdc.htm gdc@conknet.com

FOR GDC USE: Ck. No. Dog No. A: E:

Application

Globoid Cell Leukodystrophy Registry

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INSTRUCTIONS

FOR OWNER:

• Owner to complete and sign Section A
• Attach $75 lab fee check made to Dr. DavidWenger
• Enclose self addressed, stamped envelope
• When owner receives completed diagnosis from Dr. Wenger, owner should send these forms with a $10 check made to “GDC” for registration in the GDC Registry. (Fee is waived for affected or carrier dogs.)

FOR VETERINARIAN

• Veterinarian to complete and sign Section B
• Draw at least 4 cc of blood
• Use, green top tube (Heparine). Mix gently but well.
• Identify the tube with dog name and breed,. owner name, veterinarian name.
• Pack sample tube and the signed GDC application form with check and return envelope, in insulated (foam) box at room temperature.
• Ship by overnight express Monday thru Thursday to:
• Dr. David Wenger
• Lysosoml Diseases Testing Laboratory
• Jefferson Alumni Hall, Room 394
• 1020 Locust St.,
• Philadelphia, PA 19107

Dr. Wenger will report his diagnoses below on this signed application form and mail it in the self-addressed envelope to the owner.

SECTION A

For OWNER/AGENT to complete

Owner Name:____________________________________________

Co-Owner Name:____________________________________________

Address:____________________________________________

City:__________________________________

State:_____

Zip:_________

Phone:___________

Fax:___________

E-Mail:_____________________________________

Country__________

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Breed:__________________________________

Sex M____ (___N/S___) F____

Weight:________

Height:________

Registered Name of Dog:_______________________________________

Call Name:_______________________________

Birth Date:_______________

Registration No.(AKC, other) ____________________

No. Dogs in Litter:________

Breeder:___________________________

Address:________________________________________________

:____Include, if possible, a four generation pedigree is enclosed with first entry of dog into the GDC registry.

Sire's Reg. Name:_____________________________________________

Birth Date:_____________

Reg. No. ________________

Owner of Sire:___________________________________

Address:_____________________________________________

Dam's Reg. Name:_____________________________________________

Birth Date:_____________

Reg. No. : ______________

Owner of Dam:___________________________________

Address:_____________________________________________

For Owner to sign:

I hereby certify that the blood sample submitted is of the dog described on this application.

I understand that the diagnosis and other information on this sheet will be retained in the GDC or other open registry.

I authorize GDC to release this data to responsible breeders, owners, prospective owners and investigators.

Signature of owner/authorized agent:_____________________________________Date:______

SECTION B

For Veterinarian to Complete:

Dog Identification. Please check at least one method and provide the code, if known
Tattoo#	Microchip#	DNA	Coat Marking	Owner, only	Other:

Blood Sample Taken: Date:____/_____/____:

CLINICAL STATUS: Symptoms:

CLINIC/HOSPITAL
Name:	Street Address:

City:

Postal Code:

Country:

Phone:

Fax:

E-Mail:

Please print name of Veterinarian:____________________________________

Signature:____________________________________

Date________

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Report form for result of DNA analysis of globoid cell leukodystrophy (GCL) in Cairn Terriers.

GCL is a fatal, autosomal recessive disease caused by mutations in the galactocerebrosidase (GALC) gene. When a dog inherits two copies of the gene with the mutation (one copy from each parent) it will become affected with the disease. If a dog has one of the mutated GALC genes it will be healthy but could pass on the gene to offspring if mated with a non-carrier dog, or produce affected dogs if mated with another carrier.

DNA analysis of the dog identified on the Front side of this form
reveals that:	_____this individual is a carrier of the mutation causing GCL
.	_____ this individual is affected (has GCL).
.	_____ this individual is clear of globoid cell leukodystrophy.

Signature :____________________________________ Date:__________

David A. Wenger, PhD, Professor of Neurology and Biochemistry and Molecular-Pharmacology
Lysosoml Diseases Testing Laboratory, Jefferson Alumni Hall, Room 394
1020 Locust St.,Philadelphia, PA 19107
Ph: (215)-955~923 FAX: (275) 955-9554 e-mail: david.wenger@mail.tju.edu

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GDC Form Revised 1/15/04