Please Complete The form below All information provided will Remain Confidential Plumides, Romano & Johnson, PC Date Name First Last Date of Birth MM slash DD slash YYYY Social Security Number Home Address Street, Apt #, City, State, ZipCell PhoneWork PhoneHome PhoneEmail Drivers License Number State IssuedAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDate of Issued MM slash DD slash YYYY Do you have a Commercial License (CDL)YesNoPlease List Your Ticket Information BelowNC CountyAlamance CountyAlexander CountyAlleghany CountyAnson CountyAshe CountyAvery CountyBeaufort CountyBertie CountyBladen CountyBrunswick CountyBuncombe CountyBurke CountyCabarrus CountyCaldwell CountyCamden CountyCarteret CountyCaswell CountyCatawba CountyChatham CountyCherokee CountyChowan CountyClay CountyCleveland CountyColumbus CountyCraven CountyCurrituck CountyCumberland CountyDare CountyDavidson CountyDavie CountyDuplin CountyDurham CountyEdgecombe CountyForsyth CountyFranklin CountyGaston CountyGates CountyGraham CountyGranville CountyGreene CountyGuilford CountyHalifax CountyHarnett CountyHaywood CountyHenderson CountyHertford CountyHoke CountyHyde CountyIredell CountyJackson CountyJohnston CountyJones CountyLee CountyLenoir CountyLincoln CountyMacon CountyMadison CountyMartin CountyMcDowell CountyMecklenburg CountyMitchell CountyMontgomery CountyMoore CountyNash CountyNew Hanover CountyNorthampton CountyOnslow CountyOrange CountyPamlico CountyPasquotank CountyPender CountyPerquimans CountyPerson CountyPitt CountyPolk CountyRandolph CountyRichmond CountyRobeson CountyRockingham CountyRowan CountyRutherford CountySampson CountyScotland CountyStanly CountyStokes CountySurry CountySwain CountyTransylvania CountyTyrrell CountyUnion CountyVance CountyWake CountyWarren CountyWashington CountyWatauga CountyWayne CountyWilkes CountyWilson CountyYancey CountyCourt DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What speed were you clocked at Were you in a school zone?YesNoInsurance InformationHas any person on your insurance policy received a ticket in the last three years? * Yes No Has any person on your insurance policy received a Prayer for Judgement Continued (PJC) in the last three years? * * Yes No Has any person on your insurance policy been in an at-fault accident in the last three years? * Yes No Has any person on your insurance policy been in an at-fault accident in the last three years? * Yes No Legal Service AgreementConsent This Contract for Legal Services ('Agreement'), entered into by and between Plumides, Romano & Johnson, PC., hereinafter called the 'Law Firm' andEnter Your Legal First and Last Name First Last The Law Firm shall represent me solely in the traffic matter indicated on my Traffic Intake Form.* I agree to the terms listed above.* The Law Firm may waive my appearance, continue my case, plead me as charged, or plead to a lesser charge, if the Law Firm reasonably believes that it would be in my best interest.* I agree to the terms listed above.* I acknowledge that the Law Firm has made no promises to me as to the outcome of the case except that the Law Firm has promised to render their best professional skill.* I agree to the terms listed above.* I acknowledge that the fee I pay is a fee for legal services, and no portion of the fee will be returned to me regardless of the success of the case. This fee is treated as a fee for legal services, and it will be considered earned upon receipt. * I agree to the terms listed above.* I acknowledge that I shall remain responsible for all court costs, fines, fees, document costs, and all other costs as may be assessed by the court, or otherwise tied to overall fees. * I agree to the terms listed above.* I agree to accept all communications via electronic mail (email) at the email address provided in the Client Information section of this form and that I am solely responsible for contacting the Law Firm, in writing, and updating any changes in any such Client Information.* I agree to the terms listed above.* I acknowledge that the Law Firm gauges the potential outcomes of a case based on the information given on the Traffic Intake Form and that any errors in this form may cause the legal opinions of the Law Firm to not apply to the actual and correct information pertaining my case. * I agree to the terms listed above.* By checking this box and submitting this form, I acknowledge that I have read and understood all the terms stated in this Agreement and that I am binding myself to the terms of this Agreement as if I had signed the document in person.* I agree to the terms listed above.* DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pursuant to N.C.G.S. 7A-148 et al, I waive my constitutional right to appear for trial and authorize my attorney to enter a plea on my behalf. I agree to be bound by the judgment of the court, subject to the right of appeal, unless such right is waived. * * I agree to the terms listed above.* DateMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920How Did You Hear About Our Firm Or Attorneys?Referred or Search Referred by someone Found the firm through a search I found your through the following search, please choose the relevant box below. Not Applicable Google Search Facebook Ad Yellow Pages Instagram LinkedIn Twitter Yelp I was referred by: First Last Please sign below indicating your understanding that the $250.00 initial consultation fee is for today's office consultation only and that no further obligation is incurred by Plumides, Romano & Johnson, PC as a result of this consultation and that Plumides, Romano & Johnson, PC has not yet been retained to represent you in any matter.Consent If you decide to hire Plumides, Romano & Johnson, PC to represent you in any matter, you understand that you will be required to execute a formal Fee Agreement and Authority to Represent before we agree to undertake any representation.Signature First Date CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ