Full name*Nature of charges against you?*Date of Arrest / Citation / Incident* Date Format: MM slash DD slash YYYY Next court date* Date Format: MM slash DD slash YYYY Time*Prior Court Date - if any Date Format: MM slash DD slash YYYY Name of the court*Cell Phone No. or Best Phone No. during day*Best phone number, during the evening, if different:Best times to call:Is there any other person authorized to contact? If so, enter their best phone number:Step 2: Contact and Client InformationCell phone number:Home phone number:Work phone number:Other phone number:Can you receive calls at work?YesNoOK to say call is from an atty?YesNoWhat's the name of your employer?What is your job, occupation or position?Primary email address:* Is this a work email?YesNoDo you check this email daily?YesNoAccess email during the day?YesNoEnter your home address: Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Age:Date of birth:Social Security #:Step 3: Details of the Stop / Arrest / Citation / EncounterDate of the arrest? Date Format: MM slash DD slash YYYY Time of the arrest?Location (city / closest city)Street / Route NumberNearest Cross Street / ExitList the Charges written on the Traffic Ticket and/or CompliantClick the (+) to create a new line in this list.Name of ChargeStatute / Code Number Arresting Agency:Arresting Officer's NameReason For Stop or contactPast Criminal Cases – list all felonies ever & all misdemeanors in 10 yearsClick the (+) to add another year in the listYearChargeResult Below please briefly describe the nature of the matter and or provide any additional relevant informationEmailThis field is for validation purposes and should be left unchanged.