Information Release Form
(Please print this form and complete it)
Information Release Form

I have reviewed my test results and others that have been received and posted to the Reynolds Surname DNA Project website. I agree to release the following personal information for publication on the Reynolds Surname DNA Project website.

Please initial each of your choice(s) for release of information concerning the test 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
________ You may publish my mailing address (shown below)
________ You may publish my phone number:  ________________________
________ You may release my name and email address to other participants of the Reynolds Surname DNA Project, but do not publish them on the website.
Your Full Name (include middle name) (required) - - - - - - - Participant ID# (required)  
E-mail Address (required)
Street Address (required) ---------------------- Apt. No.
City/State/Zip (required)
Country (required)
Telephone Number
_________________________________ ______________
Signature ---------------------------------------- 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 complete this form and mail it to:

Reynolds Family Association
% Larry Joe Reynolds
1007 Stone Shore Street
Mount Pleasant, TX 75455-7487