Contact Information
Your Name*

Date of Birth*

Your Email*

Phone Number*

Address*

Suite/Apt. #

Zip Code*

Emergency Contact Name*

Emergency Contact Phone Number*

Background Information
Are you a U.S. Citizen?*yesno
Are you a military veteran?*yesno
What type of work do you do?*
Name of Employer*

Case Information

Case Type*DUIDomestic ViolenceBatteryDrug ChargesMisdemeanorFelonyFix Criminal RecordOther
Charges*
Date of Incident*
Location of incident*
Arrested By
Case Number
Court Date*
Blood Alcohol Content (DUI Only)

Criminal History
Have you ever failed to appear for a court date?*yesnon/a
On Probation or Parole?*yesno
Do you have prior convictions?*yesno
List Date and Charges for Prior Convictions