Dallas, TX 75234 / / Tel. 800-USA-LABS
Fax. 214-271-8322
FORENSIC CASE SUBMISSION FORM
Please attach completed case submission form to the EXTERIOR of the package containing the samples.
REFERRAL SOURCEHow did you hear about us: Cellmark Forensics Web SiteCellmark Forensics Sales RepCellmark Forensics Customer ServiceConferenceColleagueGovernment Crime LabOther: (please specify)
CASE INFORMATION
New Case for Cellmark Forensics / Name of Suspect
Add’l Submission for Cellmark Forensics Case # / Name of Victim
Offense: / Trial Date
AGENCY SHIPPING EVIDENCE
Name / Agency Case Number
Agency / Phone
Address / Fax
City/State/Zip / Email
CLIENT Same as Agency Shipping Evidence? Yes No
Name / Agency Case Number
Agency / Phone
Address / Fax
City/State/Zip / Email
PERSONS TO WHOM LABORATORY REPORTS SHOULD BE MAILED Same as Client? Yes No
Name / Name
Agency / Agency
Address / Address
City/State/Zip / City/State/Zip
Phone / Phone
Email / Email
PERSONS AUTHORIZED TO DISCUSS CASE DETAILS Same as Client? Yes No
Name / Name
Agency / Agency
Title / Title
Phone / Phone
EVIDENCE DISPOSITION
Return Evidence to Agency Shipping Evidence / Name
Return Evidence to Person Indicated to the Right / Agency
Destroy Evidence / Address
Evidence to be picked up at Cellmark Forensics / City/State/Zip
Phone
CASE HISTORY (Please provide a brief case history as it relates to DNA testing and attach any relevant documents)
If you have any questions, please contact customer service at 800-USA-LABS or by email at
EXHIBIT INVENTORY (Please list each item separately. Please photocopy this page for additional exhibits.)Exhibit No
(as assigned by shipping agency) / Description
(include condition and storage history if known) / Permission to Consume Sample
(if necessary) / Indicate Type(s) of Testing Required
(Call to discuss testing options if you need assistance)
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo / Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo / Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
YesNo /
Standard STRY-STRMinifilerMitochondrial DNAForensic PaternityBlood ScreenSemen Screen
SERVICE NOTES
Due to changes in the new FBI Quality Assurance Standards, you must answer the following question before we are permitted to start your case.
Do you anticipate that any DNA profile from this case will be entered into CODIS or searched in the CODIS database?
Yes No
Turnaround Time
Normal 5 Business days 10 Business days 15 Business days 20 Business days (for mtDNA only)
· See fee schedule for Rush Fees. Rush service cannot be guaranteed without confirmation.
· For all forensic relationship testing, please also submit the Relationship Testing form. Call 800-USA-LABS for a copy.
DNA TESTING NEEDS (Please provide information on the objective of the DNA test, specific instructions, and testing priorities.)
CLIENT AUTHORIZATION
I HEREBY AUTHORIZE CELLMARK FORENSICS TO CONDUCT TESTING ON THE SAMPLE(S) LISTED ON THIS FORM ACCORDING TO THE SPECIFICATIONS LISTED ABOVE.
Name:
Signature: Date:
BILLING/PAYMENT INFORMATION- This section must be completed before testing commences.
CONTRACT CLIENTS
Attached copy of Purchase Order or PO number:
Signed court order attached
Please send invoice to:
Name:
Agency:
Address:
City/State/Zip:
Phone:
Fax:
Email:
PRIVATE OR NON-CONTRACT CLIENTS – Must submit prepayment before testing commences.
Billing Contact:
Name:
Address:
City/State/Zip:
Phone:
Fax:
Email:
Payment is included in the form of a money order, certified check, or corporate check.
Payment by credit card is included (please see separate credit card authorization form).
Issuing Authority: The Laboratory Director and/or the Technical Leader(s)
Form-CL-08.08 3 of 3 Effective Date 11/25/13