The Carlson Company LLC

10343 Federal Blvd. Suite J- 401,Westminster, CO 80260

Request for Private Infidelity Testing
Semen and/or Male/Female DNA Detection

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Sample donor’s name ____________________________________________________________________________________Race ___________________________

Sample submitter’s name _________________________________________________________________________________Race ____________________________

Sample submitter’s email ___________________________________________________________________________________________________________________

Brief case scenario ________________________________________________________________________________________________________________________

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Test sample: type ____________________________________ brand _____________________________________ color _____________________________________

Test sample other, please describe ____________________________________________________________________________________________________________

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Number of test samples ____________

Requested Testing: Semen Detection only _______________________________________ Male/Female DNA Detection ______________________________________

Reference DNA sample if submitted please describe ______________________________________________________________________________________________

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Sample Submitter’s Signature ________________________________________________________________________________________________________________

Submission Date _____ / _____ / _____

Complete this form and submit with your test sample (s).