| |
|
(Please initial each of your choice(s) for release of information
concerning the test results): |
________ |
You may publish the pedigree I
submitted (Living persons will be removed) |
| ________ |
You may publish my E-mail
address (shown below) |
| ________ |
You may publish my name
|
| ________ |
You may publish my mailing address
(shown below) |
| ________ |
You may publish my phone number:
________________________ |
| ________ |
You may release my name
and email address to other participants of the Blair DNA Project,
put do not publish them on the website.
|
|
|
______________________________________________________________________
Your Full Name (include middle name) (required) - - - - - - -
Participant ID# (required) |
______________________________________________________
E-mail Address (required) |
_______________________________________________________
Street Address (required) ---------------------- Apt. No. |
_______________________________________________________
City/State/Zip (required) |
_______________________________________________________
Country (required) |
______________________________
Telephone Number |
_________________________________
______________
Signature ---------------------------------------- Date |
|
The
required information will be compared with your application to
verify your identity. Only those items initialled above will be
published on the website. |
