Online Screening Form

Call (404) 870-8418 or email theresa@lsalawfirm.comwith any questions.

Contact Information

Personal Information


Date of Birth

Driver's License #

Driver's License State of Issue

Employer Name

Employer Address

Job Title

Annual Salary

Incidient & Citation Information

Date of Offense

Time of Offense

County of Offense Occurrence

City of Offense Occurrence

Assigned Court Date

Citation/ TIcket #

Citation Date

Historical Information

Are you under the age of 25?

Do you have a CDL?

Have you received a ticket in the last three (3) years?

Have you received a ticket in the last twelve (12) months?

If you answered yes to any question above, please explain:

How Did Your Hear About Us?

Acknowledgement and Signature