Print out this form and mail it with your payment to: GenQuest DNA Analysis Laboratory 133 Coney Island Drive Sparks, Nevada 89431 Please complete all information to assist us in coordinating your case. Call 877-362-5227 and ask to speak to one of our knowledgeable representatives for assistance and pricing information. Person requesting test ________________________________________________________________________________ Address___________________________________________________________________________________________ City_____________________________________________State _________________________ Zip ________________ Telephone home _______________________________Work_____________________________Fax_________________ Secondary Contact______________________________________________Phone________________________________ All communications will be with the person requesting the test at the number listed above. GenQuest will notify the person requesting the test of the sample collection times and dates unless directed other wise by the person requesting the test. A $100.00 cancellation charge will be assessed in the event that the case is canceled. Mother__________________________________________City__________________________State_______Zip_______ Child1__________________________________________City__________________________ State_______Zip_______ Child2__________________________________________City__________________ ________State_______Zip_______ Alleged father____________________________________City___________________________State_______Zip_______ Parties to be scheduled together_________________________________________________________________________ Reporting information Results will be sent by US mail unless expedited shipping is arranged for an additional $12.00 charge (US delivery only). All participants in the testing are entitled to receive a copy of the test results. Payment information Call 877-362-5227 for pricing information. Prepayment and application are required before collections are scheduled. Please indicate type of payment: Visa____, MC____, Money order____, Cashier's check____, Business check____. Name as it appears on card ____________________________________________________________________________ Account number ____________________________________________ Expiration Date ____________________________ Amount______________________________________ Signature ______________________________________________ Additional comments or information:_______________________________________________________________________ __________________________________________________________________________________________________ download now home
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