JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
OS MIRZA LAW, LLC
Office: (414) 553-9266
Fax: (414) 296-8433
757 N Broadway, Suite 300
Milwaukee, WI 53202
osman@osmirzalaw.com
https://www.osmirzalaw.com
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
CLIENT INTAKE FORM
Please fill out the following set of questions to allow me to evaluate your needs ahead of scheduling.
First Name
*
Your answer
Middle Initial
*
Your answer
Last Name
*
Your answer
Date of Birth:
*
Your answer
Sex:
Female
Male
Prefer not to say
Other:
Clear selection
Address
*
Your answer
City:
*
Your answer
State:
*
Your answer
Zip:
*
Your answer
Phone:
*
Your answer
Place of Employment:
Your answer
Annual Salary
Your answer
Purpose for visit:
*
Your answer
Next Court Date (if applicable)
Case Number(s) or description:
MM
/
DD
Time
:
AM
PM
Date of Loss/Injury (if applicable)
MM
/
DD
/
YYYY
Are You:
MARRIED
SINGLE
DIVORCED
SEPARATED
WIDOWED
Clear selection
Do you currently have a Will?
Yes
No
Other:
Clear selection
Legal Interests
Bankruptcy
Patent
Copyright
Trademark
Criminal Defense
Family
Civil Lawsuit
Small Claims Lawsuit
Personal Injury
Wills/Trusts
Labor & Employment
Civil Rights
How were you referred to us?
Office Walk-in
I'm a Previous Client
Bar Association
TV
Radio
Billboard
Website
Avvo
Friend
Other:
Clear selection
I authorize emails concerning my case
*
Yes
No
I authorize emails of general interest
*
Yes
No
A copy of your responses will be emailed to the address you provided.
Submit
Page 1 of 1
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
