Traffic Intake

Please complete this form in order to assist with our handling of your traffic matter.

Contact Information

Prefix

First Name (Legal Name)*

Middle Name

Last Name*

Date of Birth*

Company (if applicable)

Email Address*

Phone Number

Street Address

City

State/Province

Zip/Postal Code

Identifying Information

Social Security Number

Driver's License

Driver's License State

Driver's License Number

Are you, or have you been, licensed in any state other than North Carolina in the last seven years? YesNo

Please list the state or states you were licensed in

Driving History

Have you, or anyone on your household insurance policy, used a PJC (Prayer for Judgment Continued) in the last five years? YesNo

If yes, please provide the date or approximate date

If the PJC is not on your personal driving record, please tell us who it was for so we can request a driving record for that individual on your household policy

Your Case

Please list any circumstances that may help our attorneys argue on your behalf. Example: special circumstances that caused you to drive faster than usual, or anything else that may put your case in a more sympathetic light. This will help our attorneys when they advocate for the best possible outcome in your case. Any details at all may be helpful.

What is your most important priority with respect to the resolution of this case?

Documents

Please scan or take a photo of your traffic citation and upload here. PDF, JPG or PNG, up to 10 MB.

Please scan or take a photo of your driver license and upload here. PDF, JPG or PNG, up to 10 MB.

One Last Step

Finally, please obtain a non-certified copy of your driving record for all states in which you have been licensed in the last seven years. North Carolina driving records can be downloaded directly from payments.ncdot.gov. You do not need to wait on the record to submit this form — send it to us as soon as you have it.

Sending this form does not create an attorney-client relationship. If you have not yet signed an engagement agreement with our office, please do not include anything you would not want disclosed.

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Traffic Intake

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