Per Diem Request Form

 

 

FILL OUT, PRINT AND SCAN EMAIL MARIAS@MSELAWYER.COM or CALL (631) 360-0226:

 

PLEASE NOTIFY OUR OFFICE PRIOR TO 4:00 PM THE DAY PRIOR TO REQUEST COVERAGE.

 

*MUST RECEIVE CONFIRMATION FROM OUR OFFICE VIA EMAIL, OR TEXT PRIOR TO APPEARANCE.

 

 

DATE AND TIME OF APPEARANCE: ____________________________________________________

 

 

NAME:

 

        LAW FIRM: ________________________________________________________________________________

 

        ATTORNEY CONTACT - FIRST: _____________________  LAST:____________________________________

 

 

EMAIL:  ______________________________________________________________________________________

 

PHONE NUMBERS:

 

       OFFICE: ______________________________________________

 

        CELL: ________________________________________________

 

        NUMBER TO SEND/RECEIVE TEXTS: ______________________________________________

 

        FAX: _______________________________________

 

OFFICE ADDRESS: ____________________________________________________________________________

 

 

 

COURT: ______________________________________________________________________________________

 

JUDGE AND PART: ____________________________________________________________________________

 

CASE NAME: _________________________________________________________________________________

 

INDEX:_______________________________________________________________________________________

 

PARTY YOUR OFFICE REPRESENTS: ____________________________________________________________

 

TYPE OF CASE: _______________________________________________________________________________

 

STATUS OF THE CASE: ________________________________________________________________________

 

_____________________________________________________________________________________________

 

 

DETAILS OF CASE AND SPECIAL INSTRUCTIONS: __________________________________________________

 

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_____________________________________________________________________________________________

 

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*attach additional sheets and/or information as needed.

 

FORM FOR LAW FIRMS, LAW FIRM STAFF AND ATTORNEYS ONLY.  

 

EMAIL NOT TO BE USED FOR SERVICE OF LEGAL PAPERS AND DOCUMENTS.