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    One DDC Way ● Fairfield, Oh 45014

    1-800-929-0815 ● 1-800-363-1707 (Fax)

    Client Identification Form

    Chain Of Custody
    Corporate Partner : AZ DNA
    Address : 6696 E Red Bird Rd,Ste 7
    C/S/Zip : Scottsdale, AZ 85266
    Phone Number : 480.695.6250
    Email :az.dna@icloud.com
    LAB USE ONLY

    Arizona-DNA-Testing-1

    To Collector: Please print clearly. Entire box must be completed for each party collected.
    Mother

    CaucasianNative AmericanHispanicBlackAsianOther (specify)


    Driver's LicenseMilitry IDOther (specify)



    YesNo


    YesNo


    YesNo

       I certify I have read and agree to the Terms and Conditions provided on this form.

    Sign Here      Mother's Signature:

    Date:
    Child

    CaucasianNative AmericanHispanicBlackAsianOther (specify)


    Driver's LicenseMilitry IDOther (specify)


    Male Female



    YesNo


    YesNo


    YesNo

       I certify I have read and agree to the Terms and Conditions provided on this form.

    Sign Here      Custodian's Signature:

    Date:
    Alleged Father

    Caucasian Native American Hispanic Black Asian Other (specify)


    Driver's LicenseMilitry IDOther (specify)



    YesNo


    YesNo


    YesNo

       I certify I have read and agree to the Terms and Conditions provided on this form.

    Sign Here      Alleged Father's Signature:

    Date:
    Additional Party

    CaucasianNative AmericanHispanicBlackAsianOther (specify)


    Driver's LicenseMilitry IDOther (specify)


    Male Female



    YesNo


    YesNo


    YesNo

       I certify I have read and agree to the Terms and Conditions provided on this form.

    Sign Here      Additional Party's Signature:

    Date:

    Collecter Statement

    I certify that I have properly identified the parties and have collected, packaged and sealed the specimen(s) and have witnessed the signatures. I affirm under penalities for perjury, that no tampering with the specimen(s) occurred while under my control.

    AM PM

    Collection Facility Information

    (If different from address above)

    COC-4002-CA 180302-DF

    Mother's Contact Information_________________________________

    Alleged Father's Contact Information_________________________________

    Additional Party's Contact Information_________________________________

    I certify that I have properly identified the parties and have collected, packaged and sealed the specimen(s) and have witnessed the signatures.

    I Certify I have read and agree to the Terms and Conditions provided.

    Terms and Conditions

    I acknowledge, consent, and agree to the following:

    • I verify that the information contained on this form is correct and true to the best of my knowledge.
    • I authorize DDC, or its agents, to collect biological specimens and perform DNA testing with my specimen or that of the minor or incapacitated individual(S) name on this form.
    • I understand that the biological specimens will be used for genetic testing and may be stored for future testing.
    • f this test involves a person who is a minor or who is otherwise legally incapable of consenting, I attest that I have the legal authority to consent to test and assume all legal responsibility.
    • I witnessed the labeling of my name and/or individual's name I am consenting for on the envelope/tube or package containing the specimen.
    • I acknowledge and agree that the laboratory's liability to me arising out of or in any way related to the provision of testing services contemplated herein shall not be held liable if it is unable to produce test results due to insufficient specimens or due to the nature or condition of the specimenDDC may request additional samples.
    • I understand that to ensure testing of the highest quality DDC reserves the right to perform more testing to satisfy strict laboratory standards and guidelines. If this process delays the reporting of results. I will not hold DDC or the entities collecting specimens liable for any refund or damages.

    DNA Diagnostics Center Laboratory Use Only

    Package Received Sealed and Secure:Yes No

    I hereby affirm that I received the specimens for the individuals named on this form and found no evidence that the specimens had been tampered with or that the package had been opened prior to our receipt.





    AMPM