Criminal Law Form

Referred by

Are you a

Type of offense

Date of arrest

County of arrest

Charges

Prior arrest/convictions

Name

First Last

Company

Title

Email Address

Home Phone

Work Phone

Cell Phone

Fax

Preferred method of contact

When is the best time to contact you?

Safe Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth date

Driver's license number

Social Security Number

Alternate/Emergency Contact

Name

First Last

Relationship to client

Phone

Email

Preferred method to receive billing statement

Disclaimer*

I certify that the information provided is true and correct to the best of my knowledge.

Brief description of incident(s) leading to arrest/charges

Comments

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