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 contactBelow please briefly describe the nature of the matter and or provide any additional relevant informationPast traffic record last 2 yearsClick the (+) to add another year in the listYearChargeResult CommentsThis field is for validation purposes and should be left unchanged.