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Private Investigator Quality Survelillance Investigation
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Criminal and or Civil Background Check Order Form

Criminal and or Civil Background Check Order Form
Agency License #: A-98-00005
Form Type:
Type of Check: Civil Background Check
Criminal Background Check
Civil and Criminal Background Check
Claim Rep:
Claim #:
Insured:
Return To (if surveillance needs to be sent to defense counsel enter attorney name here):

Subject:
Last Known Address:
City:
State:
Zip:
Date Of Birth:
S.S. Number (Must have Social Security Number to run Civil or Criminal Background Check).:
FL DL #:
(Please list all identifying information you have as due to data truncation we do not have access to complete Social Security Numbers)
Last Known Phone Number:
Date of Loss:

Any Additional Information On Subject:
Please Specify Reason for Background Check:
Client's Comments To Investigator:

Your Contact Information
First Name:
Last Name:
Company Name:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Country:
Preferred Phone #:
Secondary Phone #:
Email Address:
Defense Counsel and or Adjuster Contact Information
First Name:
Last Name:
Company Name:
Address Line1:
Address Line2:
City:
State:
Zip Code:
Country:
Preferred Phone #:
Secondary Phone #:
Email Address:

Records will be searched in each County the Subject has resided in for the past 10 years

Information
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Shannon Investigations, Inc.
P.O. Box 15945
Plantation, FL 33318

Phone:
(954) 797-9410

Fax:
(954) 337-5791
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