Case Evaluation Form

Please take a few moments to complete and submit this form so that we may better serve you.

Personal Information
Mr.   Mrs.   Ms.   Dr.
First Name:
Last Name:
Date of Birth:

 

U.S. Citizen:  Yes   No
If you are not an U.S. citizen, there may be significant immigration consequences to a criminal conviction.

 
Home Address:
Apt or Suite Number:
City:
State:
County:
Zip:
Home Phone Number:
Cell Phone Number:
Pager Number:
Fax Number:
Alternate Number:
Home eMail:
Employer Information
Employer:
Your Job Title:
Work Address:
Suite or Office Number:
City:
State:
County:
Zip:
Work Phone Number:
Work eMail Address:

 

An attorney will respond to your request as soon as possible - how would you prefer we contact you?
Work Phone   Home Phone   Cell Phone   eMail Only

 

Details
Are you completing this form on behalf of someone else?  Yes   No
If yes, please provide your contact information:
First Name:
Last Name:
Phone Number:
eMail Address:
Relationship to Subject:

Briefly explain what you may need advice about or assistance with:

 

Are we the first attorneys you have consulted regarding this matter?   Yes   No

 
Do you have a court date? Where is it and when?

How would you pay for fees in this matter?
 Check   Credit Card   Cashier's Check/Money Order   Cash   Contingency Fee

 
If you don't mind, could you tell us how you found our website?
MSN Search Engine (MSN.com
Martindale-Hubble Legal Directory (Lawyers.com)
Verizon Superpages Directory (SuperPages.com)
Google Search Engine (Google.com)
AOL Search (AOL.com)
Findlaw.com (findlaw.com)
Other (please indicate):