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General Request Form
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Please complete the following form and click Submit. We will contact you as soon as possible regarding your inquiry.

Tells Us About This Request
I'm Looking For... *
Give a brief, general summary of your request.

Details of Your Legal Request
What was the date that your legal issue took place?
Please provide a brief description of your legal issue(s): *
Was a police report filed? *
Yes    No    Not Sure   
Were there any witnesses? *
Yes    No    Not Sure   
Was there an injury involved? *
Yes    No    Not Sure   

Billing Preference
Please indicate how you would prefer to pay for the services of an
attorney, should you hire us, to help you with your legal matter.
Billing preference, if you wish to hire an attorney: *
(Note: There is no charge to submit your request.)

Addtional Details
Please indicate any additional, general information that will help us
respond to your request.
Details

Your Contact Information
First Name *
 Last Name *
Street Address
City
 State
 		Zip Code
Contact Phone
 E-mail Address
How do you wish to be contacted?
Contact Comments/Note

* Required to submit this form





Priscilla Burnham
906-228-9001

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