Information About Yourself

Have you been known by any other names in the past?

Yes

Please specify.

No

Gender

Male

Female

Social Security Number

XXX-XX-XXXX

Race

White

Black

Hispanic or Latino

Asian

American Indian or Alaska Native

Native Hawaiian or Pacific Islander

Do you have a valid driver's license?

Yes

What is your driver's license number? In what state is your driver's license?

No

Marital Status

Single

Married

Spouse's Name: Date of Marriage:

Separated

Divorced

Widowed

Do you have any children?

Yes

How many children? Do the children currently live with you?

No

Are you currently employed?

Yes

Employer Name: Job Title: Employer Phone Number: Employer Address: How long with this employer?

No

Are you a veteran?

Yes

What branch?

No

II. Information About Your Criminal Record

Have you ever been convicted of a felony in federal court?

Yes

Which court?

No

Have you even been CONVICTED of assault, battery, or domestic violence in any court?

Yes

Please specify.

No

Have you ever been CHARGED with assault, battery or domestic violence in any court?

Yes

Please specify.

No

Are you currently, or have you ever been, subject to a protective order?

Yes

Please specify.

No

For each of your felony convictions in state court, select "Yes" and enter additional information about that felony.

Felony 1:

Yes

Conviction: Court: Year:

No

Felony 2:

Yes

Conviction: Court: Year:

No

Felony 3:

Yes

Conviction: Court: Year:

No

Felony 4:

Yes

Conviction: Court: Year:

No

Felony 5:

Yes

Conviction: Court: Year:

No

Do you have any additional felony convictions?

Yes

Conviction: Court: Year: Conviction: Court: Year:

No

Do you have any criminal charges currently pending?

Yes

Please specify.

No

Did you have a probation officer after your most recent felony conviction?

Yes

Probation officer: Phone number: City or county of probation:

No

Are you currently on probation?

Yes

Please specify.

No

Have your civil rights been restored by the Governor?

Yes

Please upload a copy of your Grant Order. You may request a copy here: https://www.restore.virginia.gov/.

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No

Have you been convicted of any criminal offenses since your civil rights were restored?

Yes

Please specify.

No

Are you ineligible or legally barred from purchasing, possessing or transporting a firearm under the laws of the Commonwealth of Virginia or any other state for any OTHER reason?

Yes

Please specify.

No

III. Information for Your Request to Restore Your Firearm Rights

Why do you want your firearm rights restored?

Since your conviction, have you completed or obtained any of the following? (Select all that apply.)

Re-entry programsProfessional licensesTraining or school coursesAward, honors or other recognitions

Please describe how you've been involved in your community since your last felony conviction.

Please describe how and why you've changed since your last felony conviction.

How were you referred to our law firm?

Friend or family member

Input the person's full name:

Another attorney

Input the attorney's full name:

Online search or lawyer directory website

Input the name of the website:

For example, "Avvo", "Facebook", or "LawFirmName.com"

Billboard, bus stop, phone book, newspaper, or other physical advertisement

Where was the ad located?

Radio or TV advertisement

What radio or TV station?

Bar Association

Which Bar Association?

Other

Please explain how you found us:

Please use this space to provide the attorney with any additional information that may be relevant.

ACKNOWLEDGEMENT AND ACCEPTANCE

I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.

THANK YOU