Submit Case | Pure Gold Forensics

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PURE GOLD FORENSICS

12 Nevada Street, Suite C

Redlands, CA 92373

Case Submission

Agency Case Number(Required)

Submitting Agency(Required)

Contact Name(Required)

Current Date(Required)

Select all that apply(Required)

Initial Evidence Submission

Additional Submission

CODIS Request

Authorized Point(s) of Contact

Name(Required)

First Last

Agency

Phone(Required)

Fax

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is there another contact you'd like to add?(Required)

Yes

2nd Point of Contact Info

Name

First Last

Agency

Phone

Fax

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mailing Address

Name(Required)

First Last

Agency

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Is the mailing and billing address the same?(Required)

Yes

Is the mailing address the same as the Evidence return address?(Required)

Yes

Billing Address

Name

First Last

Agency

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Evidence return address

Name

First Last

Agency

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Case info

Suspect Name(Required)

Victim Name(Required)

Charged Offense(Required)

Case Summary(Required)

Evidence List

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

ITEM #

Consumption Permitted

TESTING REQUESTED

Additional Comments

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED ON THIS CASE SUBMISSION FORM IS ACCURATE TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE PURE GOLD FORENSICS, INC. TO CONDUCT THE REQUESTED TESTING ON THE SAMPLES LISTED ABOVE IN ACCORDANCE WITH ITS STANDARD PROCEDURES, TERMS AND CONDITIONS. I UNDERSTAND THAT I WILL BE CHARGED ACCORDING TO THE APPLICABLE FEE SCHEDULE OR CONTRACT.

Authorized Signatory's Name (print)

First Last

Signature(Required)

APAPPX20 v0324
Effective Date: 3/4/24 TV

Case Submission

Authorized Point(s) of Contact

2nd Point of Contact Info

Mailing Address

Billing Address

Evidence return address

Case info

Evidence List

(909) 793-3820

info@puregoldforensics.com

Mailing Address:

P.O. Box 688

Redlands, CA 92373

Physical Address:

12 Nevada Street, Suite C

Redlands, CA 92373