VETERANS CONSORTIUM PRO-BONO PROGRAM ATTORNEY TRAINING APPLICATION AND CONTACT FORM

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1. First Name

First Name

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2. Last Name

Last Name

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3. Contact Information

Contact Information   Company:
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP/Postal Code:
Email Address:

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4. Telephone/Fax

Telephone/Fax   Telephone Direct
Fax Direct
Telephone Firm
Fax Firm

5. Size of Organization/Firm

Size of Organization/Firm   small (under 10)

medium (over 10 under 50)

large (over 50)

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6. Have you previously applied for or attended a PBP training?

Have you previously applied for or attended a PBP training?   Yes

No

7. Location and date of training you are interested in attending (if known)

Location and date of training you are interested in attending (if known)

8. How did you find out about the Pro Bono Program?

How did you find out about the Pro Bono Program?

9. Organization's/Firm's Pro-Bono Contact (if any):

Organization's/Firm's Pro-Bono Contact (if any):

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10. Type of Practice

Law FirmIndividual (Solo) PractitionerPublic Interest OrganizationStudentOther

Type of Practice

11. When (date) are you available to take a case (leave blank if no restriction)?

When (date) are you available to take a case (leave blank if no restriction)?

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12. Bar status

ActiveInactive

Bar status

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13. State in which you are Licensed (NA if not licensed)

AL AlabamaAK AlaskaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFL FloridaGA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaOH OhioOK OklahomaOR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY WyomingNA Not applicable

State in which you are Licensed (NA if not licensed)

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14. Bar Number (if your state does not issue bar numbers, enter NA)

Bar Number (if your state does not issue bar numbers, enter NA)

15. If you are admitted to more than one Bar, place the information in the box below

If you are admitted to more than one Bar, place the information in the box below

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16. Have you been the subject of a disciplinary complaint or refused admission to practice, disbarred, suspended, reprimanded, sanctioned, or held in contempt by any court, administrative agency or regulatory body?

YesNo

Have you been the subject of a disciplinary complaint or refused admission to practice, disbarred, suspended, reprimanded, sanctioned, or held in contempt by any court, administrative agency or regulatory body?

If yes, please explain

17. Any additional comments?

Any additional comments?