Confidential Emergency Information Form

EMERGENCY INFORMATION FORM

**Strictly Confidential And Protected By Attorney-Client Privilege**
*IMPORTANT NOTES WHEN FILLING OUT FORM:*

If there is a required (*) field that you are unable to answer at this time, you may use "N/A" EXCEPT WHEN ENTERING PHONE NUMBERS AND EMAIL ADDRESSES.
1) Please provide a minimum of 1 emergency contact (someone who we can contact if you are arrested and/or charged Include full name, phone number, email address, and how they are related).
Emergency Contact 1 Name*
Emergency Contact 1 Phone number*
Please enter a valid phone number.
Emergency Contact 1 Email address
example@example.com
Emergency Contact 1 Relationship to you*
Emergency Contact Additional Notes:
Use this field to provide any additional contact notes. Ex) International phone number +44 1234 1234 12
Are we authorized to discuss the details of your case with Emergency Contact 1?*

YesNo
Emergency Contact 2 Name
Emergency Contact 2 Phone number
Emergency Contact 2 Email address
example@example.com
Emergency Contact 2 Relationship to you
Are we authorized to discuss the details of your case with Emergency Contact 2?

YesNo
Emergency Contact 3 Name
Emergency Contact 3 Phone number
Emergency Contact 3 Email address
example@example.com
Emergency Contact 3 Relationship to you
Are we authorized to discuss the details of your case with Emergency Contact 3?

YesNo

2) In the event you are arrested, do you have any bail bonds company that you'd prefer to use?*

YesNo
a. Name of the bail bonds company*
b. Phone number for bail bonds company*
c. Contact at the bail bonds company (if any)
3) Do you have a local criminal defense attorney who you’d like us to retain as local counsel in your state? (local counsel is required for Pro Hac Vice representation). If you reside in Arizona, please disregard this question as the Attorneys For Freedom Law Firm is your local representation.*

YesNo
a. Local Attorney's Name
b. Local Attorney's Firm name
c. Local Attorney's Phone number
d. Local Attorney's Email address
e. Local Attorney's Website address
If you have more than one preferred criminal defense attorney, please enter their contact information below:

RELEASE CONDITIONS INTERVIEW

The information provided in this section will be crucial in the event of an arrest
4 ) Do you have any prior criminal convictions?*

YesNoDecline to Answer
a. What is the offense of conviction?*
b. In which Court?*
c. When was the case resolved? (approximate dates)*

MonthDayYear
Date
d. Did you serve time in prison? If so, how long?*
e. Are you a prohibited possessor?*

25) Please provide the following information (needed for self-defense):
a. Your current age
b. Your height
c. Your current weight
d. Your date of birth
Additional Information:
Feel free to add any additional information you would like to share with us (permits, licenses medications, contacts, etc.)
Full Legal Name*
Your Email*
Please be sure to use the SAME EMAIL ADDRESS for this form that you used when you signed up with AOR. Using a different email will cause our system to not recognize that you completed the form, resulting in unwanted email reminders.
Today's Date*

MonthDayYear
Date
Infusionsoft Tags

Release Conditions Interview - Completed - TRIGGERRelease Conditions Interview - UPDATED
Should be Empty:

EMERGENCY INFORMATION FORM