Client Intake Form - JOEL J KIRKPATRICK PC

First Name *

Last Name

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Email Address *

Phone *

Are you a current/former federal employee? *YesNo

Please identify the matter for which you are seeking assistance: *Proposed Agency DisciplineSecurity Clearance IssueDiscrimination/EEO claimWhistleblower Retaliation ClaimOther Federal Employment Matter

Please identify the matter for which you are seeking assistance: *Criminal Defense MatterFederal Firearms Issue (e.g., FFL/Gun Dealer Compliance or Related Matters)Other Legal Matter

Please identify the proposed discipline you are seeking assistance with: *SuspensionRemovalInterviewOther

Is this proposed suspension/actions of 14 days or less? *YesNo

Please attach the notice

No file chosen

Is this a suspension of 15 days or greater, demotion, and/or removal? *15 Days or greaterDemotionRemoval

Is this a proposal for indefinite suspension? *YesNo

Provide the proposed date of notice

Date you received a proposed notice

Please attach the proposed discipline notice or final notice.

No file chosen

Is this a proposal for removal from Federal service? *YesNo

Provide the proposed date of notice

Date you received a proposed notice

Please attach the proposed discipline notice or final notice.

No file chosen

Is this a final notice of removal? *YesNo

Provide the proposed date of notice

Date you received a proposed notice

Please attach the proposed discipline notice or final notice.

No file chosen

Are you contacting us because you have been informed you will be interviewed by the agency for potential misconduct? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you been contacted by Internal Affairs or an Investigator regarding a scheduled interview? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Is this a suspension of security clearance? *YesNo

Provide the date of notice

The date you received a notice

Please attach notice or final notice.

No file chosen

Is this a preliminary decision to revoke security clearance? *YesNo

Provide the date of notice

The date you received a notice

Please attach notice or final notice.

No file chosen

Have you filed an informal counseling with the agency? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you filed a formal complaint of discrimination? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you filed with the agency? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you filed with the OSC (Office of Special Counsel)? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Please provide a brief description of your matter and upload any related documents associated.

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Is this a federal criminal matter? *YesNo

Is this a state criminal matter? *YesNo

Is this a local criminal matter? *YesNo

Have you been charged with a felony? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you been charged with a misdemeanor? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you not yet been charged but believe you may be charged? *YesNo

Please provide a brief description

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Have you received a revocation of your FFL license? *YesNo

Please attach notice or final notice.

No file chosen

Provide the date of notice

The date you received a notice

Have you received a denial of an FFL license? *YesNo

Please attach notice or final notice.

No file chosen

Provide the date of notice

The date you received a notice

Are you contacting us about another firearm-related matter? *YesNo

Please provide a brief description.

Please attach documents related to the above, i.e., indictment, charging document, or other relevant paperwork.

No file chosen

Please provide a description of the matter you are contacting us about

Please attach any relevant documents.

No file chosen

Please provide a brief description

Work Details

Agency Employer *

Agency Street Address *

Agency Apartment, suite, etc

Agency City *

Agency State/Province *

Agency ZIP / Postal Code *

Agency Country *

Agency Phone Number *

Position Title *

Occupational Series, Cluster, Pay Band/Step *

Years of Service with Current Agency *

Enter On Duty Date *

Total Years of Service with the Federal Government, including Military *

Referral Details

Referral name *

Network Event Name *

Network Event Location *

Date Attended *