Your Case Details

Full Name

Home Address

City and State

Zip Code

Home Tel

Mobile

Preferred Means of Communication

Date of Birth

Driver LIC. #

Business Name & Address

Business Telephone

Where to Send Confidential Mail

Where to Leave Voice-Mail

Citizenship / Immigration / U.S Residency Status

Emergency Contact Name, Address & Tel.

Arrest Date

Next Court Date

Charges

Court / Branch / Dept.

Bail AMT

Bail Posted?

Bail Bond Agency

Priors, if Any

Referred By

Have You Made Any Statements or Been Interviewed?

Police Report or Citation? [Agency & RPT.#]

Time, Location & Description of Incident, Accident or Arrest

Other Party(s)

Witnesses

Prior Military Service

How did you hear about Gasner Criminal Law?

Criminal Defense Law Firm