20 



(Field Sheet) 



Owner No. 



Farm Name 



P. O. Address 



Telephone Report to be telephoned 



Number in flock Breed 



Total collected Hens Pullets Males 



Date collected Shipped By 



Percent pullet production 



Total new leg bands Season of last test 



Pail numbers Cartridge numbers 



Received at laboratory Test fluid 



Testing Plan Class, of Test 



Agglutination No 



Signed.. 



Blood Collector 



