Law Offices of Chris M. Ingram
Retainer Agreement
I have read the above retainer agreement and agree to the above terms
Enter Case Number
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Case Type
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{{$index+1}} - {{cType.revised_name}}
Intake Specialist
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Primary Contact
First Name
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First Name
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Middle Name
Last Name
*
Gender
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Male
Female
Age
Code
Phone Number
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Alt Phone Number
Date of Birth
*
Email
*
Alt Email 1
Street Address
Apartment/Suite
City
State/Region
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Zip/Postal Code
Country
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In Which Country Were You Born?
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What is Your Country of Citizenship?
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Which Country are You Living in Now?
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Do you currently have a visa?
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Yes
No
Type
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Expiry Date:
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Are you currently in the U.S. on a Visa?
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Yes
No
Current Visa Status
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Expiry Date:
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Visa Requested?
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{{$index+1}} - {{ct.revised_name}}
Relocation Time Frame?
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How did you find us?
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Google Search
LinkedIn
Facebook
Friends
Landing page
Other
Background / Outline Your Situation
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Are you currently living / working on a visa?
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Yes
No
Date of Last Entry
*
Date of I-94 Departure
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Date of Last Entry
N/A
Date of I-94 Departure
N/A
Do you have a criminal record?
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Yes
No
Description
Are you married?
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Yes
No
Do you have children?
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Yes
No
If yes, how many
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Child {{$index+1}} First Name
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Child {{$index+1}} Last Name
*
Date of Birth
*
Age
Current Visa
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Expiry Date
*
Current Visa
N/A
Expiry Date
N/A
U.S. Citizen
Secondary Contact
First Name
*
Last Name
*
Date of Birth
*
Age
Email Address
Alt Email 1
Phone Number
Address - Same as Spouse
Yes
No
City
State/Region
Zip/Postal Code
Country
Citizenship
*
U.S. Citizen
Alien Citizen
Do you have a visa type preference?
*
Do you have a visa type preference?
*
Where are you from originally?
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Where are you living now?
*
Do you currently have a visa?
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Yes
No
Type
*
Expiry Date
*
Do you have criminal record?
*
Yes
No
Description
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Billing Information
Payment Method
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Credit / Debit
Wire Transfer / Other
Proof of Transfer (Only PDF,JPEG,JPG,PNG)
*
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Agreed Attorney Fees
Attorney Fee Deposit Payable Today
(50%)
Shipping and Handling +5%
Case Printing and Packaging +5%
Total to be Paid Today
Card Number
*
Expiry Month
*
Expiry Year
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CVC/CVV
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Name On Card
*
Street Address
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City
*
Zip Code
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Category Selections
Please select your three to five categories.
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Primary Case Worker A
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Primary Case Worker B
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