Client Intake Form - signature required

Company Name

^•Last name

^•First name

Birthdate

^•Address (Primary) - Street

^•Address (Primary) - Street2

^•Address (Primary) - City

^•Address (Primary) - State

^•Address (Primary) - Zipcode

^•Phone (Primary)

^•Email (Primary)

Occupation

Employer

^•Describe the problem you are seeking help for:

^•What is the outcome you want to achieve?

Disclosure: Please be advised that our representation of you does not commence until we receive a signed Attorney Retainer/Fee Agreement and the payment initial retainer when you decide to hire our firm as your attorney.

Important: Nothing in our statements to you made during the consultation will be construed as a promise, or guarantee about the outcome of the matter, or feasibility of the transaction. We make no such promises or guarantees. Our comments about the outcome of the matter are expressions of opinion only.

^•Signature