Case Intake Form

 

Your Details:   Please supply your full contact information. Note: fields marked with an * are required and must be completed.
First Name:	*
Last Name:	*
Company:	(If Applicable)
Address:	*
Address 2:
City:	*
State:	*
Zip Code:
Country:	(if non US)
Telephone:	* (203-555-1212)
Extension:	(If Applicable)
Fax:	(203-555-1212)
E-mail:	*
Social Security #
Date of Birth:
Drivers License #
Contact @:	AM:    PM:  ANY:
Method:	Phone    Email   Mail
Investigation Type, Budget & Due Date    Please choose one which best describes your request.
	Case Type Primary Theft or Fraud Surveillance IPR, Counterfeiting or Piracy Domestic or Private Matter Database Research Background Check Asset Investigation Locate Pre-employment Screening Litigation Support Interviews & Statements Technical Services Secondary Case Type Theft or Fraud Surveillance IPR, Counterfeiting or Piracy Domestic or Private Matter Database Research Background Check Asset Investigation Locate Pre-employment Screening Litigation Support Interviews & Statements Technical Services Budget 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days 8 Days 9 Days 10 Days $500.00 $550.00 $600.00 $650.00 $700.00 $750.00 $800.00 $850.00 $900.00 $950.00 $1000.00 $1100.00 $1200.00 $1300.00 $1400.00 $1500.00 $2000.00 $2500.00
Complete By:	(Please include reason)
Reason for Request    Please outline the reason you require this investigation.
	*
Relationship to Subject:	* (Family, Friend, Creditor, Employer, etc.)
Subject Details     Please provide as much information as possible about the subject or your investigation.
Your Case/File #
Full (Proper) Name:	(Example: John Q. Public)
or Company Name:
(Last Known) Address:
Address2:
City:
State:
Zip:
Country:	(if non US)
Telephone:	(203-555-1212)
E-mail Address:	(johndoe@aol.com)
Social Security #	Male:   Female:
Date of Birth:	or Approximate Age:
Marital Status:	(Single, Married, Divorced, Separated or Widowed)
Automobile Make:	(Ford, Mercedes-Benz, Pontiac, GM etc. )
Automobile Model:	(2 door, 4 door, SUV, Pickup, Truck etc.)
Automobile Color:
Automobile Registration / Tag #	(Example: 333-CAR Note: "-" is used to indicate where there is a separation between numbers or letters.)
State of Registration:
Identifying Features
Height:	feet inches
Weight:	lbs.
Hair Color:	Length/Style:
Eye Color:
Race:	(White, Black, Hispanic, Asian e.g.: Chinese), etc.
Distinguishing Marks:	(Scars, Tattoos, Piercings etc.)
	Please include below ANY further information you know about the subject, such as the High school or college attended, type of work they do (or did), city or state of birth, what city or state you believe or know they live in now, professional memberships i.e. unions, accountant, dentist, likes and dislikes, hobbies, etc. EVERY detail you can give may help us solve your case more quickly.
Other Details:
Other Request:
	Please send literature Use discretion when contacting me
Please note: Submitting this form does not constitute a contract or agreement that Diogenes LLC will perform any services on your behalf. Once we receive your information, we will review your case and an agent will contact you by the method you have chosen above to discuss your options. All information supplied is kept strictly confidential. A case is considered accepted when an INVESTIGATIVE SERVICES AGREEMENT has been fully executed and submitted to Diogenes LLC. If the client elects not to, or fails to, complete and submit the INVESTIGATIVE SERVICES AGREEMENT, the client acknowledges and approves that the standard (default) published provisions of the agreement will apply. Only the final written quoted rates and costs fields may be modified for the purposes of the standard (default) published INVESTIGATIVE SERVICES AGREEMENT. Certification and Affidavit: By submitting this online form, I hereby certify and affirm that the information supplied above is true and accurate to the best of my knowledge at this time. I further represent and affirm that I am authorized to order and financially contract for this assignment and am not prohibited by any court order to conduct said investigation. I understand that my knowingly supplying false or misleading information may result in my case being rejected. I will forfeit any and all funds that may be paid to the Agency pertaining to this case if any information is discovered to be false, misleading, or compromising the ethical and/or legal obligations of the agency . I have read and agree to the conditions stated above *

You can also complete all fields, print the page, and fax to 702.548.9566. Make sure your printer is able to print the entire page width.

If you prefer to assign a case by other means, you may contact us by telephone (203.264.6802). Please have available all information that is referenced on this web page.

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