LEWIS Surname DNA Project
Information Release Form

I agree to release the following personal information for publication on the LEWIS Surname DNA Project website at http://www.lewissurnamednaproject.com. 

(Please initial each of your choice(s) for release of information):

________ You may publish my Y-chromosome DNA results
________ You may publish the pedigree I submitted (Living persons will be removed)
________ You may publish my E-mail address (shown below)
________ You may publish my name

_____________________________________________     
Participant's Full Name (include middle name) (required)    

__________________________________________________

Participant Kit ID# (required)

_____________________________________________
Street Address (required)

_____________________________________________
City/State/Zip/Country (required)

_____________________________________________
Sponsor's Name (if applicable)

_____________________________________________
Contact E-mail Address (required)

_____________________________________________
Contact Telephone Number

_______________________________________________________________      
Signature (Participant or Sponsor)                                                         Date

The required information will be compared with your application to verify your identity. Only those items initialed above will be published on the website.

Please print and complete this form and mail to:

Janet Crain
4600 BCR 103
Lampasas, Texas 76550