McGinnis & Associés

Client identification

Company :

First name :

Last name :

Phone number (office) :

Email :

Adress :

City :

Postal code :

Service required :

Number of days required :

Information about the employee or subject

Name of the employee or subject :

Date of birth :

Adress :

City :

Postal code :

Phone number (rsidential) :

Phone number (mobile) :

Email :

Spouse :

Children :

Number of children:

Occupation:

Adress of the employer:

Vehicle 1:

Vehicle 2:

Physical description

Gender:

Nationality :

Size :

Weight :

Hair :

Others characteristics :

Mandate

Record number :

Nature of the incapacity:

Restrictions :

Beginning of the incapacity :

Medical appointment (date):

Medical appointement (hour) :

Clinic - hospital :

Doctor :

Adress of the medical clinic :

Other relevant information :

Other known addresses :

Other people close to employee or subject :

Subject identification

Photo du sujet :

Confirmation

This form is a request of investigation which authorizes the McGinnis & associates firm to make the diverse wanted checks. Investigation McGinnis & associates makes a commitment to protect the confidential information and to reveal the results of its investigation only to the applicant or to the legal adviser of this one with a written authorization of the applicant.

I accept the terms of the form :

Date :