Criminal Defense Form

*Name:

Street Address:

City:

State:
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Zip:

Home Phone:

Okay to call you at this number?
Yes No

Work Phone:

Okay to call you at this number?
Yes No

Cell Phone:

Okay to call you at this number?
Yes No

*Email Address:

How did you find this website?

Date of Arrest:

County of Arrest:

Date of Birth:

Any prior criminal record?
Yes No

If so, state date and location of each prior conviction:

Are you now on probation or parole?
Yes No

For this case, consulted with other attorneys?

Any appointments scheduled with other attorneys?

Charge 1:

Charge 2:

Charge 3:

Charge 4:

Charge 5:

Charge 6:

Charge 7:

Case No.:

Name of Court?

Trial Date:

Trial Time:

Additional Comments: