Sheldon I. Cohen & Assoc.

Information Request Form
To submit information about your problem complete and submit this form along with payment for the initial consultation. Attorney -client confidentiality cannot be assured by email because of non-secured communications. To insure confidentiality submit information by fax or mail. The fee for initial telephone or office consultation is $100. VISA or MasterCard accepted. If it appears from the information on the form that we cannot help and no consultation is scheduled we will return the initial $100 fee. A schedule or further fees is available on request.  * =Required field
  Contact Information
Full Name:  *
Home Address:
Home Phone:  * (ex: 202-555-1234)
Work Phone:     (ex: 202-555-1234)  Extension:
Fax Number:
Email:  *
  Problem Overview
Type of Problem:  *
Name of Employer:  *
Position or Grade:  *
Legal Action Pending:
Where & When if Filed:
Results:
(2 lines only)
Pending Deadline:
Nature of Problem::  
   
   
  Payment Detail (all fields required)*
Credit Card Number:     PIN Number: (last 3 #s on back of card)
Name on Card:  
Expiration:  (ex: 05/08) Card Type:     
Billing Address: Same as Home Address above
 


Mail: 2009 N. 14th Street, Suite 708, Arlington, Virginia 22201
Call: (703)522-1200
 Fax: (703)522-1250
E-Mail: sicohen@sheldoncohen.com