DNA Request Form "*" indicates required fields Agency Requestor Contact InformationEnter your agency and contact information. DFS will only respond to agency-issued e-mail addresses.Agency Name* Name* First Name Last Name Agency E-mail address* Enter Email Confirm Email Contact Phone*Agency Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code DNA InformationI am requesting information regarding whether the following individual’s DNA profile is in Virginia’s DNA Data Bank pursuant to Virginia Code § 19.2-310.5.Name of Individual* First Name Last Name Known Aliases Date of Birth* MM slash DD slash YYYY Social Security Number Race*Select OptionWhiteBlackHispanicAsian or Pacific IslanderAmerican Indian or Alaskan NativeUnknownGender*Select OptionMaleFemaleUnknownVA State Identification Number SignaturePlease sign below to authorize the request and accept the terms.By [signing] below, I hereby certify that (1) I am a sworn law enforcement officer, and (2) this information is being obtained in furtherance of an official investigation of a criminal offense that occurred within the jurisdiction of my law enforcement agency. I understand that, under Virginia Code § 19.2-310.6, any person who disseminates, receives, or otherwise uses or attempts to so use information in the Data Bank, knowing that such dissemination, receipt, or use is for a purpose other than as authorized by law, shall be guilty of a Class 1 misdemeanor.Signature* NameThis field is for validation purposes and should be left unchanged.
