Ivey-Ivie-Ivy
Surname DNA Project
Information Release Form
I agree to release the following personal information for publication on the
Ivey-Ivie-Ivy Surname DNA Project website at http://www.jlivey.net/dna
or http://www.jlivey.com/dna.
(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 initialled above will be published on the website.
Please print and complete this form and mail to:
Jerry L Ivey
800 E. 15th Street, Suite 210
Plano, TX
75074