Space Reserved for Laboratory Document Management Bar Code

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2300 Stratford Avenue Willow Grove, Pennsylvania 19090-0437

T 215.366.1328 800.522.6671 F 215.366.1501 E crimelab@nmslabs.com www.nmslabs.com

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-CRIME LAB FORENSIC BIOLOGY/DNA REQUISITION FORM In order to process your case efficiently, this form must be filled out entirely. Please submit the completed form by email or fax. A copy of the form must also be submitted with the evidence. For new clients, prepayment must accompany samples submitted using this form. Please contact NMS Labs Client Services at CrimeLab@NMSLabs.com or (215) 366-1328 with any questions. Thank you.

Submitting Agency Information (the party that will receive the laboratory report [no private individuals]):

Agency Name:

Address:

City: State: Zip:

Requesting Officer/Contact Person:

Phone: Fax:

Email:

Authorized Provider #: (professional licensure required)

Have you used NMS Labs before? Yes NMS Labs Account #: No

New Clients Only Payment Information (Supply Check #): Submit Credit Card Information on Page 5

_______________________________________________________

Select Type of Service:

Standard Testing Service Rush Testing Service (7-10 days) SUBJECT TO RESTRICTIONS. AVAILABILITY AND ADDITIONAL FEES APPLY.

Please contact NMS Labs prior to submission of a RUSH Case.

Databasing Service

If STR data is obtained, will entry into CODIS be requested?

Yes, I’d like to be contacted for a CODIS Consultation. No NOTE: Private forensic DNA laboratories do not have access to enter or search samples in CODIS. If “yes” is marked, NMS Labs will contact the client for a CODIS Consultation prior to contacting the appropriate National DNA Index System (NDIS) laboratory Technical Leader. This communication will occur prior to the initiation of this case. Please be aware that this may increase turnaround time. If requesting RUSH services, approval from appropriate NDIS laboratory is required before RUSH service can be approved.

Delivery of Evidence Items:

Evidence items must be hand delivered or shipped using a traceable carrier (i.e. FedEx, UPS, DHL, Priority Mail). Overnight shipping is recommended. Ship or deliver to:

NMS Labs Crime Laboratory 2300 Stratford Avenue

Willow Grove, Pennsylvania 19090-0437 Packages must be properly sealed and secured during transport as per acceptable legal requirements. Seal in a tamper proof manner with seals initialed and dated. Improperly sealed packages will be rejected and returned to the submitting agency.

Space Reserved for Laboratory Document Management Bar Code

Bar Code Label Only

2300 Stratford Avenue Willow Grove, Pennsylvania 19090-0437

T 215.366.1328 800.522.6671 F 215.366.1501 E crimelab@nmslabs.com www.nmslabs.com

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Case/Sample Information (information pertaining to the case/sample being submitted):

Submitting Agency Reference/Case #:

Name(s) D.O.B. Race/Sex Victim(s): Suspect(s): Elimination(s): Case Background: Case Type: Please include a synopsis of the investigation and/or affidavit for probable cause with this submission form. Consultation between NMS Labs and the investigator/prosecutor will take place regarding the need for additional information (i.e.. photos). Attach additional sheets as needed. Select a Type of Evidence Return Service:

Discard, no return required In person evidence pick-up Ship using Traceable Carrier Unless otherwise specified, all returned evidence will be sent to the address listed on this form following delivery of the case report. Failure to notify NMS Labs in writing of a request for storage beyond the routine period(s) will be considered authorization to discard or destroy the sample(s).

Space Reserved for Laboratory Document Management Bar Code

Bar Code Label Only

2300 Stratford Avenue Willow Grove, Pennsylvania 19090-0437

T 215.366.1328 800.522.6671 F 215.366.1501 E crimelab@nmslabs.com www.nmslabs.com

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Case Consultation:

Have you had an initial case consultation with a laboratory technician? Yes No

If Yes, list the name of the technician you worked with: _______________________________

Test Request(s):

Agency Item#

Description of Evidence Examine For Permission to Consume?*

Previous Testing Performed?

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA

Serology: Blood ID Saliva ID Semen ID Other_______________________ Yes No

Yes No If Yes, where? ______________ DNA Testing:

Yes No Touch DNA *If Yes, is checked for permission to consume, please attach a formal letter from the proper authority allowing the evidence to be consumed. **Additional pages may be attached as needed.

Space Reserved for Laboratory Document Management Bar Code

Bar Code Label Only

2300 Stratford Avenue Willow Grove, Pennsylvania 19090-0437

T 215.366.1328 800.522.6671 F 215.366.1501 E crimelab@nmslabs.com www.nmslabs.com

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Chain of Custody (start with submitting agency (hospital, crime lab) – Use only if necessary: Date Relinquished By Received By Purpose of Transfer

Billing Requests: Specify any special billing instructions:

Space Reserved for Laboratory Document Management Bar Code

Bar Code Label Only

2300 Stratford Avenue Willow Grove, Pennsylvania 19090-0437

T 215.366.1328 800.522.6671 F 215.366.1501 E crimelab@nmslabs.com www.nmslabs.com

CREDIT AUTHORIZATION

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NMS LABS CREDIT CARD AUTHORIZATION FORM All fees must be pre-paid prior to beginning any testing/services as a result of the testing/services ordered on this case.

By signing below, the credit card holder agrees to pay all fees associated with the testing services requested by the authorized agent ordering such services. When the specimen is submitted, the credit card holder will be billed upon completion of all testing. Invoices are generated at the end of each month. The charge(s) will appear on your credit card statement as “National Medical Services.”

Please provide the Visa, MasterCard or American Express card number, expiration date, security code (3-digit code on the back of the

card at the end of the card number) and name as it appears on the card.

Note: Personal checks are not accepted.

Card Holder Name:

Name as it appears on card (if different):

Billing Address:

Credit Card Information:

Visa #: Exp. Date: 3-digit security code:

MasterCard #: Exp. Date: 3-digit security code:

American Exp #: Exp. Date: 4-digit security code:

Card Holder’s Telephone #:

NMS Labs will not discuss any information concerning the case with any facility/agency or individual without written permission from the client facility/agency submitting the sample(s). The submitting client on record is the authorized agent ordering the analyses and the location to receive the final results (unless otherwise instructed). I hereby authorize NMS Labs to charge the credit card number I have provided as payment for all analyses associated with the submitted case.

Credit Card Holder Signature: Date:

For NMS Use Only: CSR: Date Sent: