Intake Form Your Information Your Name: Your Email Address: Address: City / State / Zip Phone Number Date of Birth Social Security No: Driver's License Number: Marital Status: Please Select One Married Single Divorced Separated Name of Spouse: Spouse's Soc. Sec. No: Children's Names Age: Age: Age: Your Empoloyment Position: Business Name: Business Address: City / State / Zip Criminal Charge Information Present Offense: Date of Arrest:     Booking Number:     Bondsman: Present Attorney: Attorney's Phone Number: Referred By: Next Court Appearance: Time:     Court:     Retainer: Have You Made Any Statements?: If so, to Whom?: Did You Sign Any Statement?: - - - Yes No     Was it Recorded?:      - - - Yes No If Statement Made, What Did You Say In Your Statement?: Prior Offense Information Prior Offense: Date:       Convicted?:     - - - Yes No If So, What Was Your Sentence?: Other Prior Offense: Date:       Convicted?:     - - - Yes No If So, What Was Your Sentence?: Other Prior Offense: Date:       Convicted?:     - - - Yes No If So, What Was Your Sentence?: Witness Information Name of Witness: Phone Number: Home Address: (if known) City / State / Zip Name of Witness: Phone Number: Home Address: (if known) City / State / Zip Acknowledgment - Send Information Please read statement at right and check box to proceed. By checking the box to the left, I understand that the Law Offices of Rosen and Zimmerman, APLC has not agreed to represent me in any matter and that in the event an offer of representation is made I will be offered a written retainer agreement signed by Howard S. Rosen or Paul Zimmerman which will define the scope of my representation. I also understand that in the event an offer of representation is made, representation does not begin until the total retainer has been paid and in the event the retainer is paid by check, representation does not begin until said check has cleared. Submit Form >>> Top of Page