FUNERAL PROCESSION ESCORT & ARMED SECURITY REQUEST

FUNERAL PROCESSION ESCORT & ARMED SECURITY REQUEST

1645 Palm Beach Lakes Blvd, STE 1200 West Palm Beach FL, 33401 Office: 855-305-2022 Email: synergyelitesru@gmail.com
Deceased Name
Contract #
Director Name*
Phone Number*
Service Date*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Start Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
End Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number Of Escort Vehicles Requested*
2ND STOP IF NEEDED

CONTINUATION FROM 1ST STOP (PICKUP)
Time

Hour Minutes

AM/PM Option
Start Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
End Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number Of Escort Vehicles Requested
Funeral Home Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name ( ON-SITE PERSON WE CAN CONTACT)*

First NameLast Name
Phone Number ( ON-SITE PERSON WE CAN CONTACT)*
Please enter a valid phone number.
Would you like to receive an email and or text message confirmation?
TEXT OR EMAIL FOR CONFIRMATION
Special Note/ Request (i.e. Horse and carriage pick up)
Director Signature*

Clear
Date*

MonthDayYear
Date
Special Note/ Request (i.e. Horse and carriage pick up)

1645 Palm Beach Lakes Blvd, STE 1200 West Palm Beach FL, 33401 Office: 855-305-2022Email: synergyelitesru@gmail.com
Should be Empty:

2ND STOP IF NEEDED