Intake Information Form New Client General Intake Form Client contact information and reason for engaging Clark & Bellamy’s legal services Formal Name of the Client* The owner and contact person might differ. Identify the client here.HiddenClient Street Address Please provide a Physical Street Address and list any PO Box or mail drop below.HiddenApartment, suite, PO Box, mail drop, etc If applicable, you may list the Client’s PO Box or Mail Drop for the mailing address.Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code HiddenCity, State, Zip (Client) Email Address (Client)* The client will enter a separate address for the primary contact person or employee if different than the client.Entity Type (if applicable)Sole ProprietorshipLLCCorporation (for profit)Non-profit corporationOtherIf the client is a business, please select an entity type. Other Entity Type State Organized (if LLC/Corporation, etc) Land Phone Number (Client) Mobile Phone Number (Client) Fax (Client) Contact Person is Same as the Owner?* Yes No CONTACT INFORMATION(IF DIFFERENT THAN THE CLIENT)Name of Contact Person Title of Contact Person Email Address (Contact) Land Phone Number (Contact) Mobile Phone Number (Contact) Street Address (Contact) Apartment, suite, etc (Contact) City, State, Zip (Contact) HiddenServicesDESCRIPTION OF THE SERVICES REQUESTED*Please describe the specific legal services that you request Clark & Bellamy to provide the client.Agreement*By clicking the Submit button below you electronically agree to Clark & Bellamy, P.C.’s website Terms of Use, Privacy Policy, and the Firm’s General Engagement Terms. Click to Consent CAPTCHA Δ
