CONFIDENTIAL INFORMATION FORM



GAY, JACKSON & MCNALLY L.L.P.CONFIDENTIAL INFORMATION FORMNAME: ________________________DATE:MAILING ADDRESS: STREETP.O. BOX CITYSTATECOUNTYZIP CODEPHYSICAL ADDRESS:___________________________________________________PHONE: Home: Work: Fax: Cell: __________________________Other:_______________________________Date of Birth:______ Driver’s License #: SS#: EMPLOYER: PHONE: Home: Work: Fax:OPPOSING PARTY: ADDRESS: _ How were you referred to us? _________Friend _______Yellow Pages ________Central Carolina Legal Services NC Bar Assoc. Referral Services ___________ OtherCONSULTATION IS REGARDING:Domestic Matter (Divorce, Child Support, Custody, Property Settlement, Alimony)Condemnation or Land Dispute________Incorporation of BusinessPersonal Injury or Workers Comp. ClaimMedical MalpracticeDefense of Lawsuit against MeLandlord/Tenant DisputeCollection of Money Owed to MeWill or Estate Matter Criminal/Traffic ViolationsContract or Business MatterReal Estate (Deed, Closing, etc.)OtherCONSULTATION FEES: $200.00*** THERE WILL BE A $100 FEE FOR RESETTING MISSED COURT DATES***NONENGAGEMENT NOTICE: By signing below, I acknowledge that I am consulting Gay & Jackson, L.L.P. for the purposes of determining the need for legal representation, if any, and that no further obligation is incurred by either party as a result of this conference. I understand that no attorney-client relationship will exist unless and until I execute a formal written agreement for a specific matter to be handled by attorney.***Date:Signature:OFFICE USE ONLY:Attorney: Assistant: File No.:Matter:FEE:Hourly _________Retainer ________ Fixed Fee Contingent _________Court Costs _______DMV Costs _____________ Other __________________Need/Have: / Waiver / DMV Record/ Financial Affidavit / DL 123 / Criminal Record/ ED Affidavit / CCIS / Medical Release/ Other:_____________Court Date/Time/LocationNORTH CAROLINAIN THE GENERAL COURT OF JUSTICEDISTRICT COURT DIVISION_______ COUNTYFILE #: _________________COURT DATE: ___________STATE OF NORTH CAROLINAENTRY OF APPEARANCE/VS. WAIVER OF APPEARANCE/JURY TRIAL __________________________ENTRY OF APPEARANCEThe undersigned attorney respectfully enters his appearance for representation of the above named defendant on the charge(s) of:Pursuant to Article 4, Chapter 15A of the General Statutes of North Carolina, representation of the above named defendant is limited to District Court Proceedings.This the _____ day of __________, 20_____.______________________________Attorney for DefendantWAIVER OF APPEARANCE/PROFESSIONAL SERVICES AGREEMENTI hereby retain the Law Office of Gay & Jackson, L.L.P. to represent me regarding the above mentioned charge(s). I waive my right to court appointed counsel (if applicable),my right to jury trial and my right to appear in court and grant to my attorney authority to conclude the matter(s) in my best interest as if I were present. This the _____ day of __________, 20_____.______________________________Defendant ................
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