Midwest Protection Agency
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(763) 421-2966
Midwest Protection Agency
Patrol & security experts that give you peace of mind
Prisoner Transport Order Form
Please fax all required paperwork to 763-592-7862
Customer name
*
Address
*
City
*
State
*
ZIP
Email address
*
Phone number
*
Prisoner Name
*
AKA
DOB
Sex
Male
Female
Height
Weight
Hair Color
Eye Color
Type of Move
Last Day For Pickup
Requested Drop Date
Current Charges
Criminal History
History of Assault
Yes
No
History of Escape
Yes
No
Medical Condition
Medical Equipment Required
Holding Agency Name
Contact Person
Address
City
State
ZIP
Phone
Fax
Hours
Special Requirements
Destination Facility Name
Contact Name
Address
City
State
ZIP
Phone number
Fax
Hours
Special Requirements
Destination Facility Name
Contact Name
Address
City
State
ZIP
Phone number
Fax
Hours
Special Requirements
Person Authorizing this Transport
Please select at least one option.
When placing this order with Midwest Protection Agency, you agree that Midwest Protection Agency will not be liable for medical costs associated with emergency, or non-emergency medical care or pre-existing medical conditions while in Midwest Protection Agency’s custody. All prisoner medical costs, including, but not limited to, the costs of transportation to and from any medical facility shall be paid by the customer agency. Midwest Protection Agency is authorized to obtain emergency and/or routine medical treatment for the prisoner whenever deemed necessary.
*
Please select at least one option.
In the event of a customer canceling a transport after a signed prisoner transport order form is received, Midwest Protection Agency will bill you for all expenses incurred prior to a cancellation being received. Midwest Protection Agency will report all such expenditures in detail to the customer agency, under no circumstances will these expenses exceed the price quoted for the transport. Cancellation requests must be received in writing, and may be sent by fax.
*
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