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)
