New Client Form New Client Form – Traffic https://beltzlaw.com/wp-content/uploads/2010/11/Beltz-Law-Firm-Questionnaire-For-Traffic-Tickets.mp4 First Name (required) Middle Name/Initial Last Name (required) Your Email (required) *Please note that the e-mail listed above will be primary form of communication with you unless you have requested otherwise. Please read section 4.01 of the terms of service for further explanation. Cell Phone? *Required (include area code) Work Phone (include area code) Home Phone? (include area code) Address Address 2 City State Zip Code Date of Birth? Driver License Number & State Last 4 Digits of Your Social Security Number Are You a Commercial Driver? YesNo Have You Taken a Driving Safety Course in the Last Year? YesNo Is Your License Valid At This Time? Check Status Here YesNo Is There An Omni Hold On Your License? Check Status Here YesNo Ticket/Citation Number Court Who Issued the Ticket Offense (e.g. speeding, no seatbelt, etc.) Appearance Date/Bond Amount Proof of Compliance Information: Description of Offense(s): What Are Your Goals/Expectations?: Payment Method Accept Terms and Conditions?