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Participant's First Name*: |
(of
person being tested) |
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Participant's Middle Name*: |
(of
person being tested)
("NMN" = No Middle Name) |
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Participant's Last Name*: |
(of
person being tested) |
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Address1*: |
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Address2
: |
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City*: |
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State or
Other (other in second box)* |
or |
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Postal
Code* |
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Country
(in second box if not on list)*; |
or
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Telephone Number*: |
(Please include country code, if not USA or Canada) |
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Fax
Number : |
(Please include country code,
if not USA or Canada) |
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Email*: |
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Select
which test you are ordering*: |
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Would
you like to Subscribe to the Family Tree DNA Email
Newsletter?*
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Please read the Participation Agreement
below and "dot" each radio button to signify
your agreement.
Orders will NOT be placed unless
ALL boxes are checked and a 5-digit
electronic signature entered. |
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Participation Agreement
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*Item #1:
(Type "Yes" in box:)
, I want to
participate and I agree to pay
for the DNA analysis (check, money order, or credit
card) when I return my DNA sample to
Family Tree DNA at the special price of:
$ 99.00 + shipping & handling for the
Y-DNA12 Marker test
$ 169.00 +
shipping & handling
for the Y-DNA25 Marker test and
$ 229.00
+ shipping & handling
for the Y-DNA37 Marker test.
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*Item #2:
(Type "Yes" in box:)
,
after submitting this application, I will be
submitting my completed
Pedigree Chart, which
will contain my male BLAND
line back to my earliest known Bland ancestor,
based
on
original
resource documents.
I understand that that my order for the DNA Kit
will not be processed until
my Pedigree Form is received by the Foundation's DNA
Coordinator.
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*Item #3:
(Type "Yes" in box:)
, I agree to release my project Identification Number
(sent in the DNA Kit), and my ancestors' names,
chronology, locations (as I
know them to be accurate), as
well as the resulting DNA
markers, for publication on the Bland Heritage
Foundation website, but with the understanding that my
personal identity will be protected by limiting my
personal identity to only those who process my
application and results
for the purposes of comparing
with the other members of this DNA Project,
and that my personal identity with my results will
not be published
or released without my future authorization by Electronic
Signature, as I have chosen below in Item
#5.
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*Item #4:
(Type "Yes" in box:)
,
I agree that
by participating in this project, I am releasing the Bland Heritage Foundation, its Board and Officers,
of any and all legal issues that might arise out of
my participation. This includes, but is not
limited to issues involving
emotional impact from an
unanticipated DNA sequence result, samples being
lost in transit, loss of data beyond their control, and/or poor
DNA samples being provided.
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*Item #5:
(Type "Yes" in box:)
, I agree to and accept the use of the five (5) digit
numeric electronic signature I have chosen below, to
be used in lieu of my written signature, and agree
to use my 5-digit electronic signature in any future
communication requiring my authorization, including
my authorization to associate my identity with my
results, which option I will have following the
receipt of my results from the DNA laboratory.
I
hereby elect as my
5-Digit Electronic Signature*:
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COMMENTS |
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