LEGAL CONSULTATION INFORMATION REQUEST FORM

Please fill out the information requested below

Who referred you to this law office?   
__________________________________________

What is your name?     
______________________________________________________

What is your address? 
_____________________________________________________


What is your phone nos.?  
work_______________________home-___________________

What is your social security no.?  ________________________________________

If employed, what is your employer's name and address ?




Please answer the following questions.  Put X mark to indicate your answer.

i.  Have you  talked to any other lawyer about your case/problem?(     
)yes (    ) no.
ii. Have you discussed with the lawyer or any staff person of this office
about the amount and method of  payment of the legal consultation fees?    
(       ) yes        (       ) no. 
iii Do you understand that above consultation fee is only for today's one
session consultation and does not entitle you to any other legal or other
service from this law office?(     )yes(     ) no What is the consultation
fee quoted to you.  $__________.  
iv. Do you agree to pay $                  as non refundable legal fees for
this consultation? (   ) yes.  iv. How will you pay the consultation fee? 
(        ) cash      (        ) check     (       ) other. 

Please attach the consultation fee to this form. No consultation shall be
given without  the payment of fees in advance. Please request receipt, if
paying in cash. 

        I have READ and UNDERSTOOD the above questions and have answered
them truthfully to the best of my ability. I  agree to payment above stated
non refundable consultation fee in advance.

        Date: ____________                                                
______________________
                                                                Signature