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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: daliap@biosyn.com (Identity Testing Coordinator)
The DNA Identity Testing Laboratory is accredited by the American Association of Blood Banks.
  
APPLICATION FOR DNA IMMIGRATION TESTING  
  Please complete this application and fax, e-mail or mail back to arrange a DNA test for immigration. A copy of the letter from INS requesting DNA testing must be included. Please print all information. A case consultant will notify the Contact Person (in the U.S.) 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
  Maternity Test (Alleged mother and child only), $450.00
  Kinship (Sibling, Aunt/Uncle, Grandparent) Test, $500.00 for two relatives
  Each additional person, $150.00.
Number of additional people to be tested:___________________
  Network (in U.S.) DNA Collection Fee, $40.00/person:
Number of people to attend a Network DNA collection facility:_______________
 
  The above fees do not include shipping and handling, as these fees may vary by country. These fees will be confirmed with the Contact Person when the case is set up.
 
  II. Contact Information:
 
Contact Person should be: Attorney(s)  or 1st Tested Party listed on page 2
 
Attorney’s Name: ______________
Address: ______________
City: ______ State: ____
Zip: ______________
Representing: ______________
Phone: _________
Fax: _________
Attorney’s Name: ______________
Address: ______________
City: ______ State: ____
Zip: ______________
Representing: ______________
Phone: _________
Fax: _________
   
  III. Parties To Be Tested:
Contact Person’s Name: ______________________   Phone: _________
Role in this case (please check one):
Father Mother Child Brother Sister
Aunt Uncle Grandmother Grandfather    
Date of Birth: ________________________  Race: _______________________
Address: __________________________________________________
City: ________________  State: _________  Zip: ____________
Country _________________
 
Name: ______________________   Phone: _________
Role in this case (please check one):
Father Mother Child Brother Sister
Aunt Uncle Grandmother Grandfather    
Date of Birth: ________________________  Race: _______________________
Address: __________________________________________________
City: ________________  State: _________  Zip: ____________
Country _________________
 
Name: ______________________   Phone: _________
Role in this case (please check one):
Father Mother Child Brother Sister
Aunt Uncle Grandmother Grandfather    
Date of Birth: ________________________  Race: _______________________
Address: __________________________________________________
City: ________________  State: _________  Zip: ____________
Country _________________
 
Name: ______________________   Phone: _________
Role in this case (please check one):
Father Mother Child Brother Sister
Aunt Uncle Grandmother Grandfather    
Date of Birth: ________________________  Race: _______________________
Address: __________________________________________________
City: ________________  State: _________  Zip: ____________
Country _________________
 
  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)
 
  Please note that we do not schedule appointments for the parties which are outside of the U.S. The U.S. Embassy in the country from which the overseas parties are located will contact those parties to arrange an appointment for DNA collection, once the case is set up.
 
  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)    
 
  All information on this form will be used solely for this DNA analysis. No other agency or outside party will have access to this information without your written, notarized consent or without legal process.
  **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: ____________