09.17.17 | CASE INTAKE JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.Case Intake FormThank you for considering the African Law Center to represent you in your legal matter. We are delighted you choose us. In order for us to better represent you, we will need to gather certain information about you and your family.Please note, the information we gather from you is held in strict confidence and only used to assess whether or not we have the resources to properly resolve your matter.Once we have received your details, an attorney will access the information and make a determination whether to proceed or not. You will then receive a phone call to discuss this possibility and where necessary an appointment will be setup. WE DO NOT RECEIVE WALK-INS.Please be patient as we try to serve you. We take pride in the quality of our services because we exist to defend your rights.Typically you should hear back from us within 2 week of receipt of your information.Again we thank you and look forward serving you in the future.______________________________________________________Gracias por considerar al Centro de Derecho Africano para representarte en tu asunto legal. Estamos encantados de que nos elija. Para que podamos representarlo mejor, tendremos que reunir cierta información sobre usted y su familia.Tenga en cuenta que la información que obtenemos de usted se mantiene en estricta confidencialidad y sólo se utiliza para evaluar si tenemos los recursos para resolver adecuadamente su asunto.Una vez que hayamos recibido sus datos, un abogado tendrá acceso a la información y tomará la decisión de proceder o no. A continuación, recibirá una llamada telefónica para discutir esta posibilidad y, si es necesario, una cita será configurada. NO RECIBIMOS WALK-INS.Por favor sea paciente mientras tratamos de servirle. Estamos orgullosos de la calidad de nuestros servicios porque existimos para defender sus derechos.Típicamente usted debe oír detrás de nosotros en el plazo de 2 semanas de la recepción de su información.Una vez más le damos las gracias y esperamos servirle en el futuro.Sign in to Google to save your progress. Learn more* Indicates required questionPlease check one *Por favor marque unoNew Client/ Cliente nuevoReturning Client/Usuaria CLICK here https://goo.gl/forms/EkqnjJEEjzwYQLhi2RequiredIf you are a New client how did you hear about us?Si usted es un nuevo cliente cómo se entero de nosotros?ChooseInternetChurchAnother organizationWalkingWord of mouthFormer clientYelpothersFirst Name *Primero NombreYour answerLast Name *ApellidoYour answerPhone NumberNúmero de teléfonoYour answerStreet AddressNúmero de teléfonoYour answerCityCiudadYour answerStateEstadoYour answerZipcodeCódigo postalYour answerEmailYour answerWhat is your current Nationality? *¿Cuál es su nacionalidad actual?ChooseAfghanistanAkrotiriAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDhekeliaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan de Nova IslandKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabweWhen did you last enter the United States (for immigration only)Cuando fue la última vez entrar a los Estados Unidos (por la inmigración solamente)Your answerWhat kind of assistance are you seeking today? *¿Qué tipo de asistencia estás buscando hoy?ChooseImmigrationFamily lawLandlord TenantConsumer rightsWills and TrustMarital Status *Estado CivilChooseMarriedSingleWhat is the Name of your Spouse (if married)?¿Cuál es la nacionalidad de su cónyuge?Your answerWhat is the Nationality of your spouse?¿Cuál es la nacionalidad de su cónyuge?ChooseAfghanistanAkrotiriAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDhekeliaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan de Nova IslandKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabweDo you have children? *¿Tiene hijos? ChooseYesNoHow many children do you haveCuántos hijos tieneYour answerWhere are your children currently located today?¿Dónde están sus hijos actualmente ubicadas hoy en día?ChooseAfghanistanAkrotiriAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAshmore and Cartier IslandsAustraliaAustriaAzerbaijanBahamas, TheBahrainBangladeshBarbadosBassas da IndiaBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCoral Sea IslandsCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDhekeliaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropa IslandFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern and Antarctic LandsGabonGambia, TheGaza StripGeorgiaGermanyGhanaGibraltarGlorioso IslandsGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City)HondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJan MayenJapanJerseyJordanJuan de Nova IslandKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParacel IslandsParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSpratly IslandsSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTromelin IslandTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin IslandsWake IslandWallis and FutunaWest BankWestern SaharaYemenZambiaZimbabweWhat is your current legal status in America if not a US citizen?¿Cuál es su situación legal en los Estados Unidos si no es ciudadano de EE.UU.?ChooseOut of statusGreencardWork permitAsylum applicant or AsyleeotherAre you currently employed? *¿Está trabajando actualmente?ChooseYes/ siNo/ nonIf employed, name of employerSi es empleado, nombre del empleadorYour answerHow many people live in your household? *¿Cuántas personas viven en su hogar?Your answerWhat is the combined income for all household members? *¿Cuál es el ingreso combinado de todos los miembros del hogar?Your answerPlease describe as best as you can what is your specific issue and what you hope to achieve with our assistance. *Describa de la mejor manera posible cuál es su problema específico y qué espera lograr con nuestra asistencia.Your answerPlease note that filling and submitting this form is voluntary and does not in any way accord you legal representation from the African Center, Inc. Until a formal agreement has been signed by you and the African Law Center, Inc. You are not considered a client of the African Law Center, Inc. *Tenga en cuenta que el llenado y envío de este formulario es voluntaria y no de ninguna manera unánimes, la representación legal del Centro de África, Inc. Hasta un acuerdo formal ha sido firmado por usted y el Centro de la Ley de África, Inc. No se le considera un cliente del Centro de Derecho de África, IncI Agree / Estoy de acuerdoI Don't Agree / No estoy de acuerdoRequiredSubmitClear formNever submit passwords through Google Forms.This form was created inside of African Law Center, Inc.. Report Abuse Forms
