| Today's Date: |
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| Company Name: |
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| Contact Name: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Email: |
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| Safe Contact Phone Number: |
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| Number of rooms to be inspected or total sq. footage: |
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| Number of phones, Faxes, Printers: |
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| Number of Phone lines servicing address: |
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| Number of Computers to be analyzed: |
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| Number of Audio / Visual equipment: TV's I DVD's, etc.: |
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| Number of vehicles to be inspected: |
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| Preferred inspection date: |
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| Preferred inspection time: |
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| Preferred method of inspection: Covert or Open: |
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| Is this inspection for preventative reasons or other?: |
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| Are you currently involved in litigation? : |
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| Do you have a perceived threat now? : |
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| Who do you think has you or your business under surveillance? : |
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| Have you disclosed your intensions for our service's with anyone or discussed it within a suspected area? : |
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| Has your vehicle recently being broken into or have you being the victim of a burglary at your home or office ?: |
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| Have you noticed anything objects missing, moved or replaced within the suspected areas?: |
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| Have you recently received any gifts for your home or office from an unlikely source?: |
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| Are you about to bring a new product or technology to market?: |
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| Are there any major changes in your organization soon to happen?: |
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| What is the potential effect on your business if sensitive information (or trade secrets) is intercepted by an eavesdropper?: |
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| Additional information: |
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