Personal DNA Purchase Form

1
Email* This field is required.
example@example.com
2
Alleged FATHER Name* This field is required.
Mr.
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
3
Date of Birth
Date
Month
Day
Year
4
CHILD Name* This field is required.
Mr.
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
5
Date of Birth
Date
Month
Day
Year
6
MOTHER Name* This field is required.
Mr.
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Suffix
7
Date of Birth
Date
Month
Day
Year
8
$199 includes one father, child, and mother (no subsitutions)

To test an additional party (father or child), add $99 and choose the quantity
9
My Products* This field is required.
prevnext( X )
My Bag
1
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
ShippingUSD
SubtotalUSD
Total costUSD
Personal DNA Test
$199.00+Edit
Back
Additional Testing Parties?
$99.00+Edit
Back
1
1
2
3
4
5
6
7
8
9
10
Quantity
Subtotal: $0.00
Enter Coupon
Total cost $0.00
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
10
Phone Number* This field is required.
Area Code
Phone Number
11
Shipping Address (if different than Billing)* This field is required.
Street Address
Street Address Line 2
City
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State
Zip Code
Please Select
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Other
Country
12
Comments
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