Name *

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth *

MM

DD

YYYY

Do you have a Commercial Driver's License (CDL)?

Yes

No

Court date *

MM

DD

YYYY

Has anyone on your insurance policy received a ticket in the last three (3) years? *

Yes

No

Have anyone on your insurance policy received a Prayer for Judgment Continued (PJC) in the last three (3) years? *

Yes

No

Has anyone on your insurance policy been in an at-fault accident in the last three (3) years? *

Yes

No

The Law Firm may waive my appearance, continue my case, plead me as charged, or plead to a lesser change, if the Law Firm reasonably believes that it would be in my best interest. *

I agree.

I acknowledge that the Law Firm has made no promises to me as to the outcome of the case except that the Law Firm has promised to render their best professional skill. *

I agree.

I acknowledge that the fee I pay is a fee for legal services, and no portion of the fee will be returned to me regardless of the success of the case. This fee is treated as a fee for legal services, and it will be considered earned upon receipt. *

I agree.

I acknowledge that I shall remain responsible for all court costs, fines, fees, document costs, and all other costs as may be assessed by the court, or otherwise. *

I agree.

I acknowledge that the Law Firm gauges the potential outcomes of a case based on the information given on the Traffic Intake Form and that any errors in this form may cause the legal opinions of the Law Firm to not apply to the actual and correct information pertaining my case. *

I agree.

By checking this box and submitting this form, I acknowledge that I have read and understood all the terms stated in this Agreement and that I am binding myself to the terms of this Agreement as if I had signed the document in person. *

I agree.

Pursuant to N.C.G.S. 7A-148 et al, I waive my constitutional right to appear for trial and authorize my attorney to enter a plea on my behalf. I agree to be bound by the judgment of the court, subject to the right of appeal, unless such right is waived. *

I agree.