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Client Engagement Request

NELSON HARDIMAN CLIENT ENGAGEMENT REQUEST

Completing this form shall not constitute the formation of an attorney-client privilege between You and Nelson Hardiman LLP

Please ensure all information is exactly as you would like it to appear in all records and agreements.

Legal Name (Select One)(Required)

Individual

Company

Legal Name (Include any Credentials ie MD, DO, PHD, etc. )

Legal Name (LLC, LLP, PC, INC)

Please List all Owners & Officers

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Full Legal Name

First Last Title

Company (if different from client company)

Please add any others if needed.

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address(Required)

The Same

Different

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Type of Business(Required)

Business Phone(Required)

How did you hear about us?(Required)

Person Authorized to sign the Client Engagement Agreement.

Name(Required)

First Last Title

Phone(Required)

Email(Required)

Please tell us briefly about your legal needs:(Required)

Which of the following best describes your issue!(Required)

Dispute, Litigation or Investigations

Transaction/Venture

Regulatory Compliance/Advice

Are there any outside parties involved? (1)

Yes

No

Name

First Last

Relationship to you/your company

Phone

Email

Are there any other outside parties involved? (2)

Yes

No

Name

First Last

Relationship to you/your company

Phone

Email

Are there any other outside parties involved? (3)

Yes

No

Name

First Last

Relationship to you/your company

Phone

Email

Are there any other outside parties involved? (4)

Yes

No

Name

First Last

Relationship to you/your company

Phone

Email

Are there any other outside parties involved? (5)

Yes

No

Name

First Last

Relationship to you/your company

Phone

Email

Please add any other outside parties involved here if needed.

Have you been served with papers or notice of action?

Yes

No

When were you Served?

MM slash DD slash YYYY

How were you Served?

Is this a Dispute or a Law Suit?(Required)

Yes

No

Names of all adverse parties

Name

First Last Title

Company

Name

First Last Title

Company

Has a complaint been filed?

Yes

No

Please provide case number

Date of Filing

MM slash DD slash YYYY

Other relevant information

I hereby certify that all the information provided in this form is true complete and accurate to the best of my knowledge and belief.(Required)

First Last Title

Date(Required)

MM slash DD slash YYYY

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