Name
First name Middle name Last name
[                   ] [                     ] [                    ]
Address

* In order to receive results, please fill in the complete name and address where you would like your report(s) sent.

Address:         


City/State:

Zip:

Phone  Work:  Home:
E-mail                         @
Test
(check )
Paternity Identity DNA Work
Samples being
tested
Remarks  
I agree that the information on the samples is true and correct.



Signature of client:

Date:

 

 

    METHOD OF PAYMENT

    Credit Card

    Account Number

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

     

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    Expiration Date

     

     

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      Month    /      Year

    Signature                                                                                         

     

              VISA        MasterCard

    PRICE U.S. DOLLAR TOTAL                               

    Please enclose with Order Form.

    Please fill the form and send to the GENEKOTECH Inc. by either post or E-mail (genekotech@gmail.com). Sample collection may be scheduled prior to payment of tests. The full payment should be required when all of the samples are received by our laboratory.