CASE SUBMISSION FORM _____

SEROLOGICAL RESEARCH INSTITUTE

3053 Research Drive, Richmond, CA 94806

Phone: (510) 223-7374, Fax: (510) 222-8887,

SERI Case No.______Federal Tax ID # 94-2520402SERI Analyst: ______

(To be assigned by SERI)(To be assigned by SERI)

CLIENT INFORMATION:
Name / Case Number
Agency / Phone
Address / Fax
City/State/Zip / E-Mail
ADDITIONAL PERSON(S) AUTHORIZED TO DISCUSS CASE:
Name / Name
Agency / Agency
Title / Title
Phone / Phone
Address / Address
E-Mail / E-Mail
City/State/Zip / City/State/Zip
SEND ANALYTICAL REPORT TO: Same as Client Yes No
Name / Title
Agency / Phone
Address / Fax
City/State/Zip / E-Mail
BILLING INFORMATION: Same as Client Yes No
NOTE: All non-government agencies must submit prepayment by Check or Credit Card. NO CHECKS ACCEPTED FOR PRIVATE PARTY CASEWORK
Name / Pay by Credit Card Card #
Agency / Name of Card Holder
Address / Expiration 123456789101112 / 20092010201120122013201420152016201720182019 Billing Address:
City/State/Zip / Billing Address (addtnl. line):
Phone / Signature
E-Mail / Billing Under Contract/Agreement with SERI: Yes No
Fax / Court Order or Purchase Order (please include): Yes No
CASE SUBMISSON TYPE:
New Case / Reopen Existing Case - SERI Case No:
Name of Suspect(s):
Name of Victim(s):
Offense
CASE HISTORY: Please provide a brief summaryas it relates to DNA/Serology testing. Also please provide any relevant documentation (eg. permission for consumptive testing).
AGENCY SUBMITTING EVIDENCE: Same as Client Yes No
Name / Case Number
Agency / Phone
Address / Fax
City/State/Zip / E-Mail
Evidence is being dropped off at SERI Evidence is being shipped to SERI Other – Please Specify:
EVIDENCE DESCRIPTION:
Item Number / Description / OK to
Consume? / Type of Testing
Biological Screening
STR Mini-STR
Y-STR Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial MitochondrialSTR
Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial Mini-STR
Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial
Biological Screening
STR Mini-STR
Y-STR Mitochondrial
SPECIAL STORAGE REQUIREMENTS
EVIDENCE DISPOSITION:
Return to Client upon completion of case / Return to Submitting Agency
Send invoice for long term storage ($200 /6 months) / Pick up at SERI
Destroy / Return to another party (please list below)
Name / Title
Agency / Phone
Address / Fax
City/State/Zip / E-Mail

PLEASE TELL US HOW YOU HEARD ABOUT SERI? ______

CLIENT AUTHORIZATION
I authorize the Serological Research Institute (SERI) to conduct testing on the samples listed above according to the listed specifications.
Signature:______Date:_____/______/______
Print Name:______

Please submit this completed Case Submission form along with items of evidence. All items must be shipped to the address below via delivery using a traceable carrier (i.e. FedEx, UPS or USPS Priority Mail)

SHIP TO:

SEROLOGICAL RESEARCH INSTITUTE

ATTN: Evidence Technican

3053 rESEARCH dRIVE, RICHMOND, CA 94806

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