Preferred Name (if different)

If the potential client is a business or non-profit please provide 1) entity's legal business name; 2) entity's date of incorporation; 3) entity's state of incorporation; 4) list of entity's current officer names and their official titles; 5) entity's physical address; 6) entity's mailing address, if different; 7) entity's EIN; and 8) the agent listed in the entity's incorporation documents.

If potential client is a business or nonprofit please attach any certificates incorporation, bylaws, and, if applicable, IRS designation of nonprofit status.

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Preferred method of contact:

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How did you hear about Hagins | Clark?

Recommended by another attorneyRecommended by a former clientRecommended by a friend who was not a clientI am a previous clientTwitterFacebookLinkedInWebpageOther

If other, plus insert why you chose Hagins | Clark Law.

If you selected a recommendation by another attorney, former client or friend please insert their name below, so that we may thank them properly:

Case Background

What type of case do you have?

Criminal Defnse

Civil Court Case

Employment Rights / Subject of Internal Investigation / Professional Licnesing - Certification Issue

Business or Non-Profit Formation, Modification or Compliance Issue

Healthcare Compliance

Other

If other, please list the type of case you wish to discuss.

Provide a brief description of your legal issue:

Have you spoken with another attorney about your case?

Yes

Insert the name and contact information for the attorneyou you spoke with.

No

Have you received any citation, indictment, demand letter, or notified of a civil lawsuit or compliance action?

Yes

Please attach any document received by you in this matter.

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No

Please list the names of any potential witnesses, individuals, businesses, agencies or others involved in your matter whose names you know.

Are you aware of any deadlines, pending court hearings, or statute of limitations that are approaching?

Yes

If so, please list any deadlines, hearings, or statute of limitations approaching. If you have received any court notices or administrative notices please attach.

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No