Sheldon I. Cohen & Associates
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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, the fee will not be charged.
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:
(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: PO Box 4068 - Oakton, Virginia 22124
Call: (703)522-1200
Fax: (703)522-1250