SES Funeral Pickup Form

SYNERGY ELITE SECURITY SERVICES

1645 Palm Beach Lakes Blvd, STE 1200 West Palm Beach, FL 33401 / Office: 855-305-2022
Service Date (Date Requested For Escort Drivers)*

MonthDayYear
Date
Arrival Time*

Hour Minutes

AM/PM Option
Day Requested For Escort Drivers*

SUNDAYMONDAYTUESDAYWEDNESDAYTHURSDAYFRIDAYSATURDAY
One way Or Two way

ONE WAY ( 1 STOP (PICKUP & DROP OFF )TWO WAY (2 STOPS (PICK UP & DROP OFF, RE-PICKUP & FINAL DROP OFF)
Deceased Name*
Contract #
Optional for funeral home reference
Director Name*
Director Name Phone Number*
Please enter a valid phone number.
Funeral Home Phone Number*
STOP #1
Start Address*
End Address*
Number Of Escort Vehicles*
STOP # 2 (IF NEEDED)
Arrival Time

Hour Minutes

AM/PM Option
Start Address
End Address
Number Of Escort Vehicles
FUNERAL HOME INFORMATION
Funeral Home Name*
Special Note/ Request (i.e. Horse and carriage pick up)*
Name ( ON-SITE PERSON WE CAN CONTACT)*

First NameLast Name
Phone Number ( ON-SITE PERSON WE CAN CONTACT)*
Please enter a valid phone number.
Funeral Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Would you like to receive an email and or text message confirmation?*

YESNo
Email Confirmation (optional, would you like to receive email confirmation?)
example@example.com
Phone Number Confirmation (optional, would you like to receive phone call and or text messages confirmation?)
Please enter a valid phone number.
Director Signature*

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

SYNERGY ELITE SECURITY SERVICES

STOP #1

STOP # 2 (IF NEEDED)

FUNERAL HOME INFORMATION