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WILLIAM DESY, Investigative Consultant
INVESTIGATION REQUEST
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INVESTIGATION REQUEST FORM

Please print out this form, complete as much information as possible,          

(The more specific details the better).

Fax to: 619-923-9500 or cut and paste into an e-mail addressed to: wdesypi@earthlink.net

 

REQUEST DATE:___________________________TIME:___________________________CASE#:________________________________________

 

CLIENT INFORMATION:

REQUESTED BY:________________________________________________PHONE:______________________PHONE:_____________________

ADDRESS:______________________________________________________CITY___________________________ZIP_______________________

ATTORNEY______________________________________________________PHONE_________________________

 

INVESTIGATIVE SERVICES REQUESTED  (Please note any specific service requirements)

[  ]            CONSULTING - LOSS PREVENTION                                       [  ]           ACTIVITY CHECK

[  ]            CONSULTING - SECURITY AND SAFETY                               [  ]           LOCATE OR SKIP

                     

[  ]            SURVEILLANCE - # OF DAYS/ $ BUDGET  ($2000)               [  ]           RECORD RETRIEVAL

[  ]            MYSTERY SHOPPING SERVICE                                             [  ]           TENANT CHECK

[  ]            FRAUD AND THEFT INVESTIGATION                                     [  ]           OTHER SERVICES:

[  ]            BACKGROUND INVESTIGATION                                                                             ________________________________

[  ]            DOMESTIC INVESTIGATION                                                  [  ]           DO NOT EXCEED $______

[  ]            STATEMENTS AND INTERVIEWS                                          WITHOUT FURTHER APPROVAL

 

PAYMENT OPTIONS:  Checks or Money Orders made out to William Desy can be accepted in person or via mail.   DO NOT send us your Credit Card Information via email. You may pay by VISA or MASTERCARD by completing all of the following information, printing and faxing this entire packet to: 619-923-9500

Circle one: VISA or MASTERCARD

Name as it appears on the card________________________________________

Card Number_____________________________________________________

Exp.- Mo._____Year__________V-Code_______ (Last 3 digits on back of card)

Billing Address on card______________________________________________

City_______________________________State____________Zip___________

Signature_______________________________________________________

 

SUBJECT INFORMATION:

 

LAST:________________________________FIRST:_____________________________MIDDLE:_______________________AKA:_____________

 

PRIMARY ADDRESS:___________________________________________________________________________APT #:_____________________

 

STATE:________ZIPCODE_____________________ HOME PHONE:__________________________CELL:_______________________________

 

SECONDARY ADDRESS:___________________________________________________________________________APT #:_____________________

 

STATE:________ZIP CODE_____________________

 

DATE OF BIRTH:_________________CITY & STATE OF BIRTH:___________________________SSN:___________________________________

 

RACE:_______________SEX:______HEIGHT:___________WEIGHT:____________HAIR COLOR & STYLE:_______________________________

 

EYE COLOR:__________________FACIAL HAIR:______________________GLASSES:_____________TATOOS:___________________________

 

DRIVERS LICENSE #:____________________________________STATE____________BACKGROUND:__________________________________

 

MARITAL STATUS / SPOUSES NAME:______________________________________CHILDREN:_______________________________________

 

OTHER FEATURES:______________________________________________________________________________________________________

 

HABITS:________________________________________________________________________________________________________________

 

HOBBIES_______________________________________________________________________________________________________________

 

EMPLOYMENT INFORMATION:

 

EMPLOYER OR BUSINESS NAME:__________________________________________________________________________________________

 

JOB TITLE:________________________________DUTIES:_______________________________________________________________________

 

ADDRESS:____________________________________________________________________________________APT #:_____________________

 

STATE:________ZIP CODE________________ WORK PHONE:___________________________OTHER:_________________________________

 

 EMPLOYER OR BUSINESS NAME:__________________________________________________________________________________________

 

JOB TITLE:________________________________DUTIES:_______________________________________________________________________

 

ADDRESS:____________________________________________________________________________________APT #:_____________________

 

STATE:________ZIP CODE________________ WORK PHONE:___________________________OTHER:_________________________________

 

SUBJECTS VEHICLES: (IF AVAILABLE)

 

COLOR:________________________________YEAR:______MAKE:________________MODEL______________PLATE #:___________________

 

COLOR:________________________________YEAR:______MAKE:________________MODEL______________PLATE #:___________________

 

COLOR:________________________________YEAR:______MAKE:________________MODEL______________PLATE #:___________________

 

COLOR:________________________________YEAR:______MAKE:________________MODEL______________PLATE #:___________________

 

INJURY INFORMATION:

 

DATE OF LOSS:____________________________________CLAIM #:_________________________TYPE OF CLAIM:_______________________

 

INSURED:_________________________________________ALLEGED INJURY AND PHYSICAL LIMITATIONS:____________________________

 

SUBJECTS DOCTOR(S):

 

NAME:_________________________________________ADDRESS:____________________________________PHONE:____________________

 

NAME:_________________________________________ADDRESS:____________________________________PHONE:____________________

 

KNOWN APPOINTMENTS:_________________________________________________________________________________________________

 

SUBJECTS ATTORNEY:

 

NAME:_________________________________________ADDRESS:____________________________________PHONE:____________________

 

KNOWN APPOINTMENTS:_________________________________________________________________________________________________

 

SPECIAL NOTES OR INSTRUCTIONS: (Include additional sheets if necessary)