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BIO-SYNTHESIS, INC.
The DNA Identity Testing Laboratory of Bio-Synthesis, Inc. is Accredited by AABB.
 
612 E. Main Street, Lewisville, Texas 75057 Tel: (800)DNA-EXAM/(888)786-9323 (972)420-8505 (Outside US)
Fax: (972) 420-0442 Email: DNAtest@800dnaexam.com (Identity Testing Coordinator)
The DNA Identity Testing Laboratory is accredited by the American Association of Blood Banks.
  
APPLICATION FOR LEGAL DNA PATERNITY TESTING  
  Please complete this application and fax, e-mail or mail back to arrange a Legal DNA Paternity Test. Please print all information. A case consultant will notify the Contact Person to confirm receipt of the application and schedule DNA collection appointment(s)
and/or request additional information.
 
  I. Type of Test Requested (please check all that apply):
  Paternity Test (Trio of alleged father, mother and child), $450.00
  Paternity Test (Alleged father and child only), $450.00
  Network DNA Collection Fee, $40.00/person:
Number of people to attend a Network DNA collection facility:_____________
 
  II. Parties To Be Tested:
 
Alleged Father’s Name:________________ Phone:______________
Date of Birth:_______________ Race: ________________
Address:________________________________________________________________
City:___________________   State: ____________________  Zip:__________________
 
 
Mother's Name:________________ Phone:______________
Date of Birth:_______________ Race: ________________
Address:________________________________________________________________
City:___________________   State: ____________________  Zip:__________________
 
 
Child's Name:________________ Phone:______________
Date of Birth:_______________ Race: ________________
Address:________________________________________________________________
City:___________________   State: ____________________  Zip:__________________
 
  IV. Appointment(s):
 
Schedule parties:
Together: ______________
Separate:______________
Requested appointment(s) for:
Name(s) :____________________________
Day: M    T    W     R    F        Month:_________
Time : _________________  AM   PM
(If next day appointment, must be after 3:00 PM)
Schedule parties:
Together: ______________
Separate:______________
Requested appointment(s) for:
Name(s) :____________________________
Day: M    T    W     R    F        Month:_________
Time : _________________  AM   PM
(If next day appointment, must be after 3:00 PM)
 
  V. Method of Payment:
  If you choose to pay by money order or cashier’s check , make payable to Bio-Synthesis, Inc. Overseas money orders must be issued by the U.S. Postal Service. All funds must be payable in US dollars.
 
  Please check one:
 
Money Order Cashier’s Check American Express  
Visa Mastercard Discover  
  If you choose to pay with Credit Card, please complete following:
Credit Card Number: __________ Expiration Date: __________
Amount authorized: US$: __________ CVV Code: __________  
Name as it appears on the card: __________   (3 or 4 Digit on front/back of card)
Cardholder’s billing address: __________    
 
  I hereby give permission to Bio-Synthesis, Inc. to charge the above account for :
 
Deposit of US $200.00 Full amount, once confirmed with Case consultant
 
X ____________________ Date Signed ___________________
  (Signature of Cardholder)    
 
  V. Contact Information:
 
Contact Person should be:
Attorney(s) Alleged Father Mother Adult Child
   
 
Attorney’s Name: ______________
Address:______________
City : ____________  State: ______
Zip: ____________________________
Representing : __________________
PHone : _________________  
Fax : _______________
Attorney’s Name: ______________
Address:______________
City : ____________  State: ______
Zip: ____________________________
Representing : __________________
PHone : _________________  
Fax : _______________
 
 
  **FOR BIO-SYNTHESIS OFFICE USE ONLY**
 
 Scheduled appointment(s):
Name(s): ______________
Location: ______________
Day:  M   T   W   R   F       Month:_______
Time: ___________   AM     PM
 Scheduled appointment(s):
Name(s): ______________
Location: ______________
Day: M   T   W   R   F       Month:_______
Time: ___________   AM    PM
 Scheduled appointment(s):
Name(s): ______________
Location: ______________
Day:  M   T   W   R   F       Month:_______
Time: ___________   AM     PM
 Scheduled appointment(s):
Name(s): ______________
Location: ______________
Day:  M   T   W   R   F       Month:_______
Time: ___________   AM     PM
 
  Total Charge: ______________
  Deposit Paid (Minimum US$200.00):   US$___________  Date: ____________
  Balance Due:  US$___________  Date: ____________
  Paid in Full:  US$___________  Date: ____________