NC & SC Traffic Intake Form

Have You Spoken With Anyone From Our Office Yet ?

Yes

No *

First Name *

Middle Name

Last Name *

Address *

City *

State *

Country *

Zip *

Phone *

Email *

Do You Have a Commercial Drivers License (CDL)?

Driver's License Number *

State Licensed *

Date of Birth *

County *

Court Date *

Charges *

Has any person on your insurance policy received a ticket in the last three years? *

Yes

Has any person on your insurance policy received a Prayer for Judgement Continued (PJC) in the last three years? *

Yes

Has any person on your insurance policy been in an at-fault accident in the last three years? *

Yes

This Contract for Legal Services ('Agreement'), entered into by and between Browning & Long, PLLC, hereinafter called the 'Law Firm' and *

The Law Firm shall represent me solely in the traffic matter indicated on my Traffic Intake Form. *

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

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 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 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 to accept all communications via electronic mail (email) at the email address provided in the Client Information section of this form and that I am solely responsible for contacting the Law Firm, in writing, and updating any changes in any such Client Information. *

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. *

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. *

Date *

Waiver of Personal Appearance

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. *

Date *

NC & SC Traffic Intake Form

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