Professional Licensing and Certification - Questionnaire

Name:

Address (include city, state, and zip):

Telephone:

 - Home

 - Work

 - Cell

Email address:

Confirm email:

Date of birth:

Place of birth:

Gender:

-- Select -- Male Female

Employer:

Have you been given notice that any agency is planning to review your certification status or take action against your certification?

-- Select -- Yes No

What license or certification do you hold for which you have received notice of pending action?

If you hold any other licenses or certifications for which you have not received notice of pending action, please list here.

What notice have you received?

-- Select -- Notice of Administrative Investigation Notice of Probable Cause Hearing Administrative Complaint Notice of Administrative (Formal) Hearing Other

If other, please specify.

On what date did you receive notice?

What allegations have been made against you?
(To select more than one, hold down the CTRL key when selecting.)

Failing to complete continuing education Filing/registration problems Misconduct Violation of Standards Other

If other, please specify.

If any previous adverse action has been taken against your certification or license, please describe.

If any disciplinary action has been taken against you by any employer related to the present allegations, please describe.

.

How did you learn of our firm?

-- Select -- Attorney Yellow Pages Newspaper Article Web Search Other

If an attorney referred you, what is the name of the attorney or firm?

If another person referred you, what is that person's name?

Additional Information

Please provide any additional information about yourself or the case which would help the attorneys understand your potential case or explain your answers to the above questions.

Scheduling

We will contact you by phone or email unless you request some alternate means of communication.  

PLEASE READ THE FOLLOWING STATEMENTS AND INDICATE YOUR ACCEPTANCE OF THESE TERMS PRIOR
TO SUBMITTING THIS FORM.

I have prepared the answers to these questions and to the best of my ability.

THIS MUST BE ANSWERED OR YOU CANNOT SUBMIT THE FORM!

I understand that the submission of this form does not create any obligation for me or for any attorney at Delegal Law Offices. 
I further understand that submission of this form does not create an attorney-client relationship and that the lawyer is not obliged
to schedule a consultation with me.

I understand and agree that Delegal Law Offices, P.A., will have no duty to keep confidential the information that I am transmitting to the law firm through this questionnaire.


THIS MUST BE ANSWERED OR YOU CANNOT SUBMIT THE FORM!