guernsey law, global connections
property
wills, probate, trusts
matrimonial and family
personal injury
debt recovery
employment
notarial services
our people
services for individuals
commercial services
search
online injury form
key people
contact us
<table border="0" cellspacing="0" width="450" align="center"> <form action="http://www.babbelegal.com/index.php" method="post" name="online"> <input type="hidden" name="main_sub" value="63"> <input type="hidden" name="page_sub" value="12"> <input type="hidden" name="page_sub2" value="13"> <input type="hidden" name="part" value="2"> <tr> <td class="main" colspan="2"><b><font style="font-size: 14px;">Personal Injury Questionnaire - Part One: Your personal details</font></b></td> </tr> <tr> <td class="main" colspan="2"><strong>I agree to the <a href="http://www.babbelegal.com/images/site_files/16.pdf" target="_blank">Terms and Conditions</a></strong> Yes<input type="radio" name="terms_agree" value="Yes"> No<input type="radio" name="terms_agree" value="No" checked></td> </tr> <tr> <td class="main" colspan="2"><strong>Please note that fields marked with a <font color="#FF0000">*</font> are required.</strong></td> </tr> <tr> <td class="main" colspan="2"><strong>Your Details</strong></td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font>Title</strong></td> <td class="main"> <select style="border: 1px solid #3A6E8F; color: #3A6E8F;" name="title"> <option value="" selected>Please select</option> <option value="Mr.">Mr.</option> <option value="Mrs.">Mrs.</option> <option value="Ms.">Ms.</option> <option value="Dr.">Dr.</option> </select> </td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font>First Name(s)</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="firstname" size="40"></td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font>Surname</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="surname" size="40"></td> </tr> <tr> <td class="main" width="200" valign="top"><strong><font color="#FF0000">*</font>Address</strong></td> <td class="main"><textarea style="border: 1px solid #3A6E8F; color: #3A6E8F;" cols="24" rows="5" name="address"></textarea></td> </tr> <tr> <td class="main" width="200"><strong>Postcode</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="postcode" size="40"></td> </tr> <tr> <td class="main" width="200"><strong>Date of Birth</strong><br>(dd/mm/yyyy)</td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="dob_day" size="3" maxlength="2"> / <input type="text" name="dob_month" size="3" maxlength="2"> / <input type="text" name="dob_year" size="5" maxlength="4"></td> </tr> <tr> <td class="main" colspan="2"><strong>Contact Telephone Numbers</strong></td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font>Home:</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="home_tel" size="40"></td> </tr> <tr> <td class="main" width="200"><strong>Work:</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="work_tel" size="40"></td> </tr> <tr> <td class="main" width="200"><strong>Mobile:</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="mob_tel" size="40"></td> </tr> <tr> <td class="main" width="200"><strong><font color="#FF0000">*</font>Email:</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="email" size="40"></td> </tr> <tr> <td class="main" width="200"><strong>Fax:</strong></td> <td class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F;" type="text" name="fax_tel" size="40"></td> </tr> </table><br> <table border="0" cellspacing="0" width="450" align="center"> <tr> <td align="center" class="main"><input style="border: 1px solid #3A6E8F; color: #3A6E8F; background-color: white;" type="submit" name="submit" value="Next"></td> </tr> </form> </table><br>
home
guernsey: an introduction
about babbe
contact us
recruitment
the babbe library
our terms
