New Client Form

Brian Guerra - Attorney at Law

New Client Form

Please fill in all requested information. If the information requested is unknown, please indicate "unknown" in the text field.

First Name:
Last Name:
Mailing Address:
Number:
City:
State:
Zip Code:	(5 digits)
Cell Phone:	(999-000-0000)
Alternate Phone:	(999-000-0000)
Email:
DOB:	00/00/1900
DL #:
Offense Date:
Case or Ticket #:	Refer to Citation
Court Name:	In what court must you appear for your citation?
Appearance date:	Refer to Citation
DSC:	Have you taken Defensive Driving in the last year?
CDL:	Do you have a Commercial Driver's LIcense?
Referral Source:	Please be specific.
Pay Method:
Description of Event or Requested Service:
Reminder:	PLEASE BE SURE TO SUBMIT A COPY OF THE FOLLOWING: (1) DRIVER'S LICENSE, (2) CURRENT INSURANCE, AND (3) COPY OF INSURANCE CARD AT TIME OF THE OFFENSE (IF YOU HAVE A NO INSURANCE CASE PENDING). YOU MAY SUBMIT THE REQUIRED DOCUMENTS VIA EMAIL, MAIL, OR FAX. THANK YOU.