Consultation Request Form

For consultation, please fill the consultation request form and click submit.

Last Name: (Apellido):		First Name : (Nombre)
Home Address (Direccion de casa):		City (Ciudad):
State (Estado):		Zip (Codigo):
Home Phone (Telefono de casa):		Cell Phone (Numero de Celular)
E-mail address (correo electronico)
Social Security # (Numero Social):		Driver's License # (Numero de Licencia de Conducir):
Employer (Empleador):		Business Phone: (Telefono de Negocio):
Employer Address (Direccion de Empleador):		City (Ciudad):
State (Estado):		Zip (Codigo):
Occupation (Ocupacion):		Marital Status (Estado Civil):
Date of Birth (Fecha de Nacimiento):		Place of Birth (Lugar de Nacimiento):
Date You Entered the U.S. (Fecha Usted Entró en Los E.U.):		Type of Visa (Tipo de Visa):
Criminal Record (Historia Criminal):		Referred by (Recomendado(a) por):
Other Information:

Note: A fee of $85 will be charged for the consultation. Upon completion of our initial office consultation, if you desire to retain the Azarmehr & Associates, P.C. You will be required to execute and sign an Attorney/Client contract. The charge for follow up office will be $85 for each visit.

We would be happy to receive e-mail from you, however communicating with us via email does not establish an attorney-client relationship between you and Azarmehr and Associates, PC. We cannot agree to represent you until certain ethical requirements are satisfied, including determining that there are no conflicts of interest between you and other clients that we represent. Accordingly, do not send us any confidential or sensitive information until such time as we have agreed to represent you in writing, by means of a formal Engagement Letter. Any information that you send us prior to the time that we have agreed to represent you will not be treated as privileged or confidential.

In addition, the confidentiality of internet communication is uncertain and cannot be guaranteed for any persons, including current clients of Azarmehr and Associates, P.C. For this reason, if you choose to communicate with us via e-mail, you do so at the risk that your communication may be disclosed to others outside of Azarmehr and Associates.

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