How did you hear About Us? * How did you hear about our law firm? Google Yahoo Bing CraigsList BackPage National Motorist Assoc Radio Other Web Search Friend Told Me BillBoard Time & Temperature Television Other, Describe: (If google/yahoo/etc, what search terms): Name and Contact Information * First Name: * Last Name: * Street Address As Written On The Ticket: * City As Written On The Ticket: * State As Written On The Ticket: * Zip As Written On The Ticket: * Is the address that is written on the ticket your correct MAILING address? Select One YES, Address on Ticket Correct NO, Address On Ticket Not Correct Current Street Address: Current City: Current State: Current Zip: Phone and Email * Cell Phone: Home Phone: Work Phone: * Email Address: * Date Of Birth: Ticket Information * What Type of Ticket? Select Speeding Ticket No Proof Of Insurance Stop Sign Electric Signal Violation Allowing Unlicensed Driver Assault Careless Driving Child Restraint Violation Closed Road Way Construction Zone Violation Defective Brake Lights Driving While Revoked Driving While Suspended Failure To Maintain Single Lane Fake License/Altered Plates Following To Close Illegal Turn Minor In Possession No Driver License No Headlights No Operators License No Plates Paraphernalia Possession Less Than 35 Grams Racing Speeding School Zone Speed To Fast For Conditions Theft Using Park Lot Avoid Intersection Wrong Way or Wrong Side of Street Window Tint Other If Speeding How Fast? (E.G. 45 in a 20): * Ticket #: (top right-hand corner): Other Description: Did you Get a 2nd Ticket? Select Speeding Ticket No Proof Of Insurance Stop Sign Electric Signal Violation Allowing Unlicensed Driver Assault Careless Driving Child Restraint Violation Closed Road Way Construction Zone Violation Defective Brake Lights Driving While Revoked Driving While Suspended Failure To Maintain Single Lane Fake License/Altered Plates Following To Close Illegal Turn Minor In Possession No Driver License No Headlights No Operators License No Plates Paraphernalia Possession Less Than 35 Grams Racing Speeding School Zone Speed To Fast For Conditions Theft Using Park Lot Avoid Intersection Wrong Way or Wrong Side of Street Window Tint Other If Speeding How Fast? (E.G. 45 in a 20): * Ticket #: (top right-hand corner): Other Description: *Work Zone? Select One No Yes - no workers present Yes - workers present *School Zone? Select One No Yes - no children present Yes - children present * Did This Involve an Accident? Select One No Yes, but everyone is paid Yes, Matter still pending Information About The Court or Police Department *Court or Police Department that gave you the ticket: (Look at the top left-hand corner of ticket to find court name) Court Address: (This is usually found in the bottom right-hand portion of the ticket) Court Number: Court City: Court Zip: * Court Phone Number: * If there is a court date & time written on your ticket what are they? * If no court date & time is listed, give us the date on which the ticket was "issued": Information About Your Driving Record Any tickets in the last 12 months? yes no Currently on Probation for other offenses? yes no License Currently Suspended or Revoked? yes no Do you have any charges NOW PENDING in this or any other court? yes no * If YES fill in: You can also upload a picture of your ticket: (optional but recommended): I would prefer you contact me at: Home Telephone Work Telephone Cell Phone E-email
