How did you hear from us?

How did you hear about Traffic Law?

---Former ClientInternetReferralSignCraigslistBetter Business Bureau

If Other, please describe:

If you found us on Google, Yahoo, or another search engine, what search term did you use?

Name & Contact Information

First Name (required)

Last Name (required)

Street Address As Written On Ticket

City as Written on Ticket

State as Written on Ticket

Is the address that is written on the ticket your correct mailing address?

---YesNo

Current Street Address

Current City

Current State

Zipcode

Phone Number (required)

Email (required)

Ticket Information

How many tickets did you recieve when pulled over?

Date you were pulled over?

If Speeding How fast?

What was the speed limit?

Ticket Number (top right-hand corner)

Other-Description

Did you receive a second ticket?

---YesNo

Ticket Number (top right-hand corner)

Reason

Did you receive a third ticket?

---YesNo

Ticket Number (top right-hand corner)

Reason

Work Zone?

---YesNo

School Zone?

---YesNo

Did this involve an accident?

---YesNo

Information about the Court and Police Department

Police Department that gave you the ticket?

Name of the court? (usually listed near the top of the ticket)

Court Address

Court City

Court State

Court Phone Number

If there is a court date/time, please list it

Information about your driving record

Did you receive points from any tickets in the last 12 months?

---YesNo

Currently on probation for another offense?

---YesNo

Driver license currently suspended or revoked?

---YesNo

Do you have any charges now pending in this or any other court?

---YesNo

I would prefer to be contacted at

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