CONFIDENTIAL INFORMATION PAGE

CONFIDENTIAL INFORMATION PAGE

There is no charge for this preliminary investigation of your claim and all information provided by you will be held confidential.

We apologize for the detail called for by this form. Please keep in mind that an attorney's opinion is only as good as the information it is based upon. We seek, therefore, to obtain as much information as possible and to assist you in providing it by suggesting relevant content.

If you want Mr. Carrow to review the facts of your case, complete the form set out below and deliver it to Mr. Carrow by pressing the "Send Information" button at the end of the form. Do not complete or send the form, however, until you have read the Disclaimer which can be accessed by clicking here.

Please provide the following information:

E-Mail:

First Name:

Last Name:

Address

City:

State/Country:

Postal Zone:

Phone:

Fax:

Please set out below the nature and basis for your claim. You must include the name(s) of the persons against whom you may have a claim, since that information is necessary for a conflict of interest check. State as a minimum: (1) the amount of your claim (if you know) and the reason(s) why you contend you are entitled to a recovery; (2) the relevant facts and the dates that they occurred; (3) the date that you became aware, or arguably should have become aware, of the existence of your claim; (4) any problems of which you are aware that may prevent your obtaining a recovery; (5) what has been done to date, by you or anyone acting for you (e.g., an attorney) in attempting to obtain what is due you, and (6) the results. If there are any relevant documents, identify them and their significance. If your matter does not involve a money claim, set out the relevant facts and the relief you are seeking. Should you be seeking consultation or expert witness testimony on English or United States law, state the legal issue involved. If you have any questions, please call toll free in the United States at 1-800-492-1725, fax to 415-492-8419, email Mr. Carrow at robert@carrow.com or utilize the form set forth below. Mr. Carrow will respond as soon as practicable after reviewing the facts.

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