Ticket Client Information Sheet
ADVERTISEMENT
1
2
3BAILEY & GALYEN
Attorneys at Law
TICKET CLIENT INFORMATION SHEET
IF YOU HOLD A CDL LICENSE OR ARE UNDER THE AGE OF 25 PLEASE NOTIFY THE
RECEPTIONIST IMMEDIATELY FOR FURTHER INSTRUCTIONS.
SECTION 1 – To be completed by client:
Date:_______________________________
Last Name:
First Name:
Middle Initial:
Birth Date: _______________________
D.L. #__________________________ Soc. Sec. # _______________________
Mailing Address:
APT. #: ______________
City:
State:
Zip:
Home Phone:
Cell #:
I authorize emails from Bailey & Galyen.
E-Mail Address: ___________________________________________________
1. I have not made a plea with the court nor have I ever approached the court regarding this
citation(s). INI_____________
2. I understand without a copy of a current valid Driver’s License I will not be eligible for
deferred adjudication and citation will appear on my driving record. INI_____________
3. I have /have not (circle one) taken a defensive driving course within the past 12 months.
4. I have /have not (circle one) been granted deferred adjudication within the past 12 months.
How were you referred to B&G? (Circle one)
Office Sign I’m a Previous Client Bar Association B&G Letter
TV Ad
Radio Billboard In Mesquite
Website
WebChat
Phonebook: Name of book _________________________________________
Friend: Name of friend ___________________________________An Attorney: Name of attorney _______________________________
Other: ______________________________Bailey & Galyen Employee: Name of Employee_____________________________________
Have you or family member been involved in any type of accident in the last two years?
Yes_______
No_______
Have you or a family member ever suffered any serious injuries after taking a prescription or non-prescription drug? Yes_____
No _____
Do you currently have a will? Yes ________ No ________
Have you been denied Social Security benefits? Yes __________ No _________
Have you been denied Veterans benefits? Yes ________ No _________
Do you have need of legal assistance for any immigration matter? Yes_________ No _________
SECTION 2 – To be completed by law office personnel:
CITY
DATE
CITATION #
VIOLATION
Payment Amount:
Payment received by:INI________________Copy of DL:INI_______________
Cash:
Check #:
Visa:
MC:
Disc:
Amex:_______________
Card #:
Expiration Date:
1
Page
Revised 03-17-11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business