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.Format: (000) 000-0000.
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
YesNo
Emergency Contact 2 Name
Emergency Contact 2 Phone number
Format: (000) 000-0000.
Emergency Contact 2 Email address
example@example.com
Emergency Contact 2 Relationship to you
YesNo
Emergency Contact 3 Name
Emergency Contact 3 Phone number
Format: (000) 000-0000.
Emergency Contact 3 Email address
example@example.com
Emergency Contact 3 Relationship to you
YesNo

YesNo
a. Name of the bail bonds company*
b. Phone number for bail bonds company*
Format: (000) 000-0000.
c. Contact at the bail bonds company (if any)
YesNo
a. Local Attorney's Name
b. Local Attorney's Firm name
c. Local Attorney's Phone number
Format: (000) 000-0000.
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
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
Release Conditions Interview - Completed - TRIGGERRelease Conditions Interview - UPDATED
Should be Empty:

EMERGENCY INFORMATION FORM